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A  TREATISE 


THE  SCIENCE  AND  PRACTICE 


MIDWIFERY. 


BY 

W.  S.  PLAYFAIR,  M.D.,  F.R.C  P., 

PHVSrCrAN-ACCOUCHEUB   TO    H.  I.   AND  R.  H.  THE    DCCHKSS    OP  EDINBURGH  ;   PROFESSOR  OF  OBSTETRIC 

MEDICINE  IN  kino's  COLLEGE;  PHYSICIAN  FOR  THE  DISEASES  OFWOME.V  AND  CHILDKEN  TO 

kino's   COLLEGE    HOSPITAL;    CONSULTING    PHYSICIAN    TO    THE    GENERAL    LYINQ-IN 

HOSPITAL,  AND  TO  THE  EVELINA  HOSPITAL   FOR  CHILDREN  ;   PRESIDENT  OF 

THE    OBSTETRICAL   SOCIEIY    OF   LONDON;   LATE   EXAMINER   IN 

MIDWIFERY  TO  THK  UNIVEHSITY  OF  LONDON,  AND  TO 

THE  ROYAL  COLLEGE  OF  PHYSICIANS. 


THIRD  AMERICAN  EDITION, 
REVISED  AND  CORRECTED  BY  THE  AUTHOR. 

WITH  NOTES  AND  ADDITIONS 
BY 

ROBERT   P.  HARRIS,  M.D. 

WITH  TWO   PLATES  AND  ONE  HUNDRED  AND   EIGHTY-THREE   ILLUSTRATIONS. 


PHILADELPHIA; 

H  E  E"  E  Y     O .     L  E  i^. 

1880. 


Entered  according  to  xlct  of  Congress,  in  the  year  1880,  by 

HENRY     C.     LEA, 
in  the  Office  of  the  Librarian  of  Congress.     All  risrhts  reserved. 


COLLINS,    PRINTEK. 


.\\ 


TO 


T.  GAILLARD  THOMAS,  M.D., 

PROFESSOR  OF  OBSTETRICS 
IN  THE  COLLEGE  OF  PHYSICIANS  AND  SURGEOXS,   NEW  YORK. 


Dear  Dr.  Tiio:mas  : 

I  t\m  desirous  of  marking  my  gratitude  for  the  kind  reception  of  my 
book  in  America,  where  so  much  vahiable  obstetric  work  has  been  done,  by 
associating  with  the  Second  Edition  the  name  of  one  whose  many  important 
contributions  to  tlie  branch  of  Medicine  of  whicli  it  treats  have  gained  for 
him  so  great  and  so  well-deserved  a  reputation.  I  could  wish  that  it  were 
more  worthy  of  the  honor  you  do  me  in  allowing  me  to  dedicate  it  to  you ; 
but,  such  as  it  is,  I  beg  you  to  accept  it  as  a  mark  of  the  high  esteem  in 
which  you,  as  well  as  your  fellow  laborers  in  obstetric  science,  are  held  in 
the  mother  country. 

I  am,  very  faithfully  yours, 

W.  S.  PLAYFAIR. 

31  George  Street,  Hanover  Square,  1878. 


(iii) 


f  Iter  Kit  i  * 

OF  THE 


^- 


AMERICAN  PUBLISHER'S  NOTICE. 


It  will  be  seen  that  this  edition  has  been  carefully  revised  by  the 
author  specially  for  this  country,  thus  })resenting  the  subject  in  its 
latest  aspect  from  a  trans-atlantic  stand-point. 

There  still  remained  some  matters  in  which  American  opinion  and 
practice  differ  from  those  of  England,  and  these  it  has  been  the  effort 
of  the  Editor  to  present,  as  before,  in  a  manner  as  concise  as  possi- 
ble. They  chiefly  relate  to  the  use  of  forceps  and  to  the  Cci?sarean 
section.  The  statistics  of  the  latter,  as  far  as  regards  the  United 
Kingdom,  have  been  compiled  especially  for  this  work,  while  those 
of  the  United  States  will  be  found  the  most  complete  that  have 
hitherto  been  collected.  Besides  these,  a  number  of  other  points 
have  been  briefly  alluded  to,  such  as  the  progress  of  the  Porro 
operation ;  the  possibility  of  life  in  utero  after  the  death  of  the 
mother;  the  management  of  occipito-posteri  or  positions;  the  results, 
in  the  United  States,  of  the  abdominal  section  after  ruptured  uterus, 
etc.  In  all  cases  the  text  of  the  Author  has  been  left  intact,  and 
the  additions  have  been  distinguished  by  inclosure  in  brackets  [ — ]. 

Philadelphia,  December,  1879. 


(O 


TREFACE  TO  THE  THIRD  AMERICAN  EDITION. 


The  Second  American  Edition  of  my  work  on  Midwifery  "being 
exhausted  before  the  corresponding  English  Edition,  I  cannot  better 
show  my  appreciation  of  the  kind  reception  mj^  boolc  has  received 
in  the  United  States,  than  by  acceding  to  the  Pubhsher"s  request 
that  I  shoukl  myself  undertake  the  issue  of  a  third  edition.  As 
little  more  than  a  yeai"  has  elapsed  since  the  second  edition  was 
issued,  there  are  naturally  not  many  changes  to  make ;  but  I  have, 
nevertheless,  subjected  the  entire  work  to  careful  revision,  and 
introduced  into  it  a  notice  of  most  of  the  more  important  recent 
additions  to  obstetric  science.  To  the  operation  of  Gastro-Elytrot- 
oniy,  formerly  briefly  discussed  along  with  the  Ciesarean  section,  I 
have  now  devoted  a  separate  chapter.  In  the  preparation  of  this  I 
have  to  acknowledge  my  indebtedness  to  Dr.  Garrigues's  exhaustive 
article  on  the  operation,  recently  published  in  the  New  York  Med- 
ical Journal,  of  which,  indeed,  it  is  little  more  than  an  abstract. 

The  Editor  of  the  Second  American  Edition,  Dr.  Harris,  enriched 
it  with  many  valuable  notes,  of  which,  it  will  be  observed,  I  have 
freely  availed  myself. 


31    GrEOEGE    StEEET,    HaNOVER    SqUARE, 

LoxDON,  September,  1879. 


(vii) 


PREFACE  TO  THE  FIRST  EDITION. 


Those  who  have  studied  the  progress  of  Midwifery  know  that 
there  is  no  department  of  medicine  in  which  more  has  been  done 
of  late  years,  and  none  in  which  modern  views  of  practice  differ 
more  widely  from  those  prevalent  only  a  short  time  ago.  The 
Author's  object  has  been  to  place  in  the  hands  of  his  readers  an 
epitome  of  the  science  and  practice  of  midwifery  which  embodies 
all  recent  advances.  He  is  aware  that  on  certain  important  points 
he  has  recommended  practice  which  not  long  ago  w^ould  have  been 
considered  heterodox  in  the  extreme,  and  which,  even  now,  will  not 
meet  with  general  approval.  He  has,  however,  the  satisfaction  of 
knowing  that  he  has  only  done  so  after  very  deliberate  reflection, 
and  with  the  profound  conviction  that  such  changes  are  right,  and 
that  they  will  stand  the  test  of  experience.  He  has  endeavored  to 
dwell  especially  on  the  practical  part  of  the  subject,  so  as  to  make 
the  work  a  useful  guide  in  this  most  anxious  and  responsible  branch 
of  the  profession.  It  is  admitted  by  all  that  emergencies  and 
difficulties  arise  more  often  in  this  than  in  any  other  branch  of 
•practice ;  and  there  is  no  part  of  the  practitioner's  work  which 
requires  more  thorough  knowledge  or  greater  experience.  It  is, 
moreover,  a  lamentable  fact  that  students  generally  leave  their 
schools  more  ignorant  of  obstetrics  than  of  any  other  subject.  So 
long  as  the  absurd  relations  exist,  which  oblige  the  lecturer  on 
midwifery  to  attempt  the  impossible  task  of  teaching  obstetrics  in  a 
short  three  months'  course — an  absurdity  which  has  over  and  over 
again  been  pointed  out — such  must  of  necessity  be  the  case.  This 
must  be  the  Author's  excuse  for  dwelling  on  many  topics  at  greater 

(ix) 


X  PREFACE    TO    THE    FIRST    EDITION. 

length  than  some  will  doubtless  think  their  importance  merits, 
since  he  desires  to  place  in  the  hands  of  his  students  a  work  which 
may  in  some  measure  supply  the  inevitable  defects  of  his  lectures. 

Many  of  the  illustrations  are  copied  from  previous  authors,  while 
some  are  original.  The  following  quotation  from  the  preface  to 
Tyler  Smith's  "  Manual  of  Obstetrics"  will  explain  why  the  source 
of  the  copied  w^oodcuts  has  not  been  in  each  instance  acknowledged: 
"  When  I  began  to  publish,  I  determined  to  give  the  authority  for 
every  woodcut  copied  from  other  works ;  I  soon  found,  however, 
that  obstetric  authors  of  all  countries,  from  the  time  of  Mauri- 
ceau  downwards,  had  copied  each  other  so  freely  without  acknowl- 
edgment as  to  render  it  difficult  or  impossible  to  trace  the 
originals.'' 

The  Author  has  to  express  his  acknowledgments  to  many 
friends  for  their  kind  assistance  by  the  loan  of  illustrations  and 
otherwise,  and  more  especially  to  his  colleague,  Dr.  Hayes,  for 
his  valuable  aid  in  passing  the  work  through  the  press. 


31  George  Street,  Hanover  Square, 
March,  1876 


CONTENTS. 


PART    I. 


ANATOMY  AND  PHYSIOLOGY  OF  THE  ORGANS  CONCERNED  IN 

PARTURITION- 


CHAPTER  I. 

ANATOMY  OF  THE  PELVIS. 

PAGE 

Its  importance — Formation  of  Pelvis — The  os  innominatum :  its  tliree  divisions — 
Separation  between  the  True  and  False  Pelvis — the  Sacrum  and  Coccyx — Me- 
chanical relations  of  the  Sacrum — Pelvic  articulations  and  ligaments— Move- 
ments of  the  Pelvic  joints — The  Pelvis  as  a  whole — Differences  in  the  two  sexes 
— Measurements  of  the  Pelvis — Its  diameters,  planes,  and  axes — Development 
of  the  Pelvis — Soft  parts  in  connection  witli  the  Pelvis 25 

CHAPTER  II. 

THE  FEMAI.E  OENERATIVE  ORGANS. 

Division  according  to  Function:  1.  External  or  Copulative  ;  2.  Internal  or  Form- 
ative Organs — Mons  Veneris — Labia  majora  and  minora — The  Clitoris — The 
vestibule  and  orifice  of  Urethra — Passing  of  the  femal-e  catheter — Orifice  of 
Vagina— The  Hymen— The  glands  of  the  Vulva— The  Perineum— The'Vagina 
— The  Uterus  ;  its  position  and  anatomy — The  ligaments  of  the  Uterus — The 
Parovarium— The  Fallopian  Tubes — The  Ovaries — The  Graafian  Follicles,  and 
the  Ova     .....  ........     41 

CHAPTER  III. 

OVULATION  AND  MENSTRTTATION. 

Functions  of  the  Ovary — Changes  in  the  Graafian  Follicle:    1.  Maturation;   2. 
Escape  of  the  Ovum — Formation  of  the  Corpus  Luteum — Quality  and  source  of 
the  Menstrual  blood — Theory  of  Menstruation — Purpose  of  the  Menstrual  loss 
—Vicarious  Menstruation — Cessation  of  Menstruation       .         .         .         .         .73 

(xi) 


CONTENTS. 

PAET    II. 

PREGNANCY. 


CHAPTER  I. 

CONCEPTION  AND  GENERATION. 

PAGE 

The  Semen — Site  and  mode  of  Impregnation — Changes  in  the  Ovum — Cleavage 
of  the  Yelk — The  Decidua  and  its  formation — Formation  of  the  Amnion — The 
Umbilical  Vesicle  and  Allantois — The  Liquor  Amnii  and  its  uses — The  Chorion 
— The  Placenta  ;  its  formation,  anatomy,  and  functions     .         .         .         .         .86 

CHAPTER  II. 

THE  ANATOMY  AND  PHYSIOLOGY  OF  THE  FCETUS. 

Appearance  of  the  Foetus  at  A'arious  stages  of  development — Anatomy  of  the  Foetal 
Head — The  Sutures  and  Fontanelles — Influence  of  Sex  and  Race  on  the  Foetal 
Head — Position  of  the  Fo3tus  in  utero — Functions  of  the  Foetus — The  Foetal 
Circulation 109 

CHAPTER  III. 

PREGNANCY. 

Changes  in  the  form  and  dimensions  of  the  Uterus — Changes  in  the  Cervix — 
Changes  in  the  texture  of  the  Uterine  Tissues,  the  Peritoneal,  Muscular,  and 
Mucous  Coats — General  modifications  in  the  Body  produced  by  Pregnancy         .  125 

CHAPTER  IV. 

SIGNS   AND  SYMPTOMS  OF  PREGNANCY. 

Signs  of  a  fruitful  Conception — Cessation  of  Menstruation — Sympathetic  disturb- 
ances: Morning  Sickness,  etc. — Mammary  Changes — Enlargement  of  the  Ab- 
domen— Quickening  —  Intermittent  Uterine  Contractions — ^Vaginal  Signs  of 
Pregnancy — Ballottement,  etc. — Auscultatory  Signs  of  Pregnancy — Foetal  Pul- 
sations— Uterine  Souffle,  etc.     ..........  135 

CHAPTER  V. 

THE  DIFFERENTIAL  DIAGNOSIS   OF  PREGNANCY SPURIOUS    PREGNANCY 

THE  DURATION  OF  PREGNANCY SIGNS  OF  RECENT  PREGNANCY. 

Adipose  enlargement  of  the  Abdomen  —  Distension  of  the  Uterus  by  retained 
Menses,  etc. — Congestive  enlargement  of  Uterus — Ascites — Uterine  and  Ovarian 
Tumors  —  Spurious  Pregnancy:  its  Causes,  Symptoms,  and  Diagnosis — The 
duration  of  Pregnancy — Sources  of  Fallacy — Methods  of  Predicting  Date  of  De- 
livery— Protraction  of  Pregnancy — Signs  of  recent  Delivery     ....  150 


CONTENTS.  XIU 


CHAPTER  VI. 

ABNORMAL  PREGNANCY,  INCLUDING  MULTIPLE  PREGNANCY,  SUPER- 
FCETATION,  EXTRA-UTERINE  FCETATION,  AND  MISSED  LAUOK. 

PAUE 

Plflral  Births,  their  frequency  ;  Relative  frequency  in  different  Countries ; 
Causes,  etc. — Super-foetation  and  Super-fecundation — Natures — Explanation — 
Objections  to  admission  of  such  cases — Their  i>ossibility  admitted — Extra- 
Uterine  Pregnancy — Classification — Causes — Tubal  Pregnancies — Changes  in 
the  Fallopian  Tubes — Condition  of  Uterus — Progress  and  Termination — Diag- 
nosis— Treatment — Abdominal  Pregnancy  :  Description  ;  Diagnosis  ;  Treatment 
— Missed  Labor  :  its  Symptoms,  Causes,  and  Treatment    .....  160 


CHAPTER  VII. 

DISEASES  OF  PREGNANCY. 

Some  only  Sympathetic,  others  Mechanical  or  Complex  in  their  Origin — Derange- 
ments of  the  Digestive  Organs  :  Excessive  Nausea  and  Vomiting  ;  Diarrhoea ; 
Constipation  ;  Hemorrhoids  ;  Ptyalism  ;  Toothache  and  Caries  of  Teeth  ;  Affec- 
tions of  Respiratory  Organs  ;  Dyspnoea,  etc. — Palpitation — Syncope — Anaemia 
and  Chlorosis — Albuminuria      ..........  188 


CHAPTER  VIII. 

DISEASES  OF  PREGNANCY  (cOJltinued). 

Disorders  of  the  Nervous  System  :  Insomnia  ;  Headaches  and  Neuralgia ;  Paraly- 
sis ;  Chorea  ;  Disorders  of  the  Urinary  Organs  ;  Retention  of  Urine  ;  Irritability 
of  the  Bladder  ;  Incontinence  of  Urine  ;  Phosphatic  Deposits  ;  Leucorrhoea  ; 
EflFects  of  Pressure  ;  Laceration  of  Veins  ;  Displacements  of  the  Gravid  uterus  ; 
Prolapse,  Anteversion,  Retroversion — Diseases  coexisting  with  Pregnancy : 
Eruptive  Fevers  ;  Smallpox,  Measles,  Scarlet  Fever,  Continued  Fever  ;  Phthisis  ; 
Cardiac  Disease  ;  Syphilis  ;  Icterus  ;  Carcinoma ;  Pregnancy  complicated  with 
Ovarian  and  Fibroid  Tumors      ..........  201 


CHAPTER  IX. 

PATHOLOGY  OF  THE  DECIDUA  AND  OVUM. 

Pathology  of  the  Decidua — Hydrorrhoea  Gravidarum — Pathology  of  the  Chorion  ; 
Vesicular  Degeneration,  Myxoma  Fibrosum — Pathology  of  the  Placenta  ;  Blood 
Extravasations,  Fatty  Degeneration,  etc. — Pathology  of  the  Umbilical  Cord — 
Pathology  of  the  Amnion,  Hydramnios  ;  Deficiency  of  Liqiior  Amnii,  etc. — 
Pathology  of  the  Foetus  ;  Blood  Diseases  transmitted  through  the  Mother,  Small- 
pox, Measles,  and  Scarlet  Fever,  Intermittent  Fevers,  Lead-poisoning,  Syphilis 
— Inflammatory  Diseases — Dropsies — Tumors — Wounds  and  Injuries  of  the 
Fcetus — Intrauterine  Amputations — Death  of  the  Foetus   .  .         .         .         .218 


XIV  CONTEKTS. 


chaptp:r  X. 

ABORTION  AND  PREMATURE  LABOR. 

TAGS 

Importance  and  Frequency — Definition  and  Classification — Frequency — Recur- 
rence— Causes — Causes  Referable  to  Foetus — Changes  in  a  Dead  Ovum  retained 
in  Utero— Extravasations  of  Blood — Moles,  etc. — Causes  depending  on  Maternal 
State — Syphilis  ;  Causes  acting  tlirough  Nervous  System,  Physical  Causes,  etc. 
— Causes  depending  on  Morbid  States  of  Uterus — Symptoms — Preventive  Treat- 
ment— Prophylactic  Treatment — Treatment  when  Abortion  is  inevitable — After- 
treatment  ......•••••••  235 


PAET     III. 

LABOR.' 


CHAPTER  I. 

THE  PHENOMENA  OF  LABOR. 

Causes  of  Labor — Mode  in  vfhich  the  Expulsion  of  the  Child  is  effected — The 
Uterine  contraction — Mode  in  which  the  Dilatation  of  the  Cervix  is  effected — 
Rupture  of  the  Membranes — Character  and  source  of  Pains  during  Labor — 
Effect  of  Pains  on  Mother  and  Foetus — Division  of  Labor  into  Stages — Prepara- 
tory Stage — False  Pains — First  Stage — Second  Stage — Third  Stage — Mode  in 
which  the  Placenta  is  expelled — Duration  of  Labor    .         ....  248 

CHAPTER  II. 

MECHANISM  OF  DELIVERY  IN  HEAD  PRESENTATIONS. 

Importance  of  Subject— Frequency  of  Head  Presentations— The  difi'erent  positions 
of  the  Head— First  Position— Division  of  Mechanical  Movements  into  Stages- 
Flexion— Rotation— Extension— External  Rotation— Second  Position— Third 
Position— Fourth  Position— Caput  Succedaneum— Alteration  in  shape  of  Head 
from  moulding  ....  .......  261 

CHAPTER  III. 

MANAGEMENT  OP  NATURAL  LABOR. 

Preparatory  Treatment — Dress  of  Patient  during  Pregnancy — The  Obstetric  Bag 
— Duties  on  first  visiting  Patient — False  Pains — Their  Character  and  Treatment 
— Vaginal  Examination — The  Position  of  Patient — Artificial  Rupture  of  Mem- 
branes— Treatment  of  Propulsive  Stage — Relaxation  of  the  Perineum — Treat- 
ment of  Lacerations — Expulsion  of  Child — Promotion  of  Uterine  Contraction — 
Ligature  of  the  Cord — Management  of  the  Third  Stage  of  Labor — Application  of 
the  Binder — After-treatment 274 


COiN  TENTS.  XV 

CHAPTER  IV. 

ANyESTlIESIA  IN  LABOR. 

PAGE 

Agents  emijloyed — Chloral :  its  Obj(;ct  and  Mode  of  administration — Ether — 
Chloroform:  its  Use,  Objections  to,  and  Mode  of  administration         .         ,         .  288 

CHAPTER  V. 

PELVIC   I'KESENTATIONS. 
Frequency — Causes — Prognosis  to  Mother  and  Child— Diagnosis  by  Abdominal 
Palpation  and  by  Vaginal  Examination — Diflerential  Diagnosis  of  Breech,  Knee, 
and  Feet — Mechanism — Treatment— Management  of  Impacted  Breech  Presenta- 
tions   292 

CHAPTER  VI. 

PRESENTATIONS  OF  THE  FACE. 

Erroneous  Views  formerly  held  on  the  Subject — Frequency — Mode  of  Production — 
Diagnosis — Mechanism — Four  Positions  of  the  Face — Description  of  Delivery 
in  First  Face  Position — Mento-posterior  Positions  in  which  Rotation  does  not 
take  place — Prognosis — Treatment   .........  3U3 

CHAPTER  VII. 

DIFFICULT  OCCIPITO-POSTERIOR  POSITIONS. 

Causes  of  Face  to  Pubis  Delivery — Mode  of  Treatment — Upward  Pressure  on 
Forehead — Downward  Traction  on  Occiput — Use  of  Forceps — Peculiarities  of 
Forceps  Delivery       ............  313 

CHAPTER  VIII. 

PRESENTATIONS  OF  SHOULDER,  ARM,  OR  TRUNK COMPLEX 

PRESENTATIONS PROLAPSE  OF  THE  FUNIS. 

Position  of  the  Fn3tus— Division  into  Dorso-anterior  and  Dorso-posterior  Posi- 
tions—Causes—Prognosis and  Frequency— Diagnosis— Mode  of  distinguishing 
Position  of  Child— Differential  Diagnosis  of  Shoulder,  Elbow,  and  Hand— 
Mechanism— The  Two  possible  Modes  of  Delivery  by  the  Natural  Powers- 
Spontaneous  Version— Spontaneous  Evolution— Treatment— Complex  Presenta- 
tion :  Foot  or  Hand  with  Head,  Hand  and  Feet  together— Dorsal  Displacement 
of  the  Arm— Prolapse  of  the  umbilical  Cord— Frequency— Prognosis— Causes— 
Diagnosis— Postural  Treatment— Artificial  Reposition— Treatment  when  Repo- 
sition fails  ........•••••  -jl' 

CHAPTER  IX. 

PROLONGED  AND  PRECIPITATE  LABORS. 

Evil  effects  of  Prolonged  Labor— Influence  of  the  Stage  of  Labor  in  Protraction — 
Delay  in  First  Stage  rarely  serious— Temporary  Cessation  of  Pains — Symptoms 


Xvi  CONTENTS. 

PAGE 

of  Protraction  in  the  Second  Stage — State  of  tlie  Uterus  in  Protracted  Labor — 
Cases  of  Protraction  due  to  Morbid  condition  of  the  expulsive  powers — Causes  of 
Protraction — Treatment — Oxytocic  remedies — Ergot  of  Eye,  etc. — ^Manual  Pres- 
sure— Instrumental  Delivery — Precipitate  Labor — Its  Causes  and  Treatment     .  332 


CHAPTER  X. 

LABOR  OBSTRUCTED  BY  FAULTY  CONDITION  OP  THE  SOFT  PARTS. 

Rigidity  of  the  Cervix  :  its  Causes,  Effects,  and  Treatment — Bands  and  Cicatrices 
in  the  Vagina — Extreme  rigidity  of  the  Perineum — Labor  complicated  with 
Tumor — Vaginal  Cystocele — Calculus — Hernial  Protrusions — ffidema  of  Vulva 
— Haematic  Effusions,  etc.  ..........  346 

CHAPTER  XI. 

DIFFICULT  LABOR  DEPENDING  ON  SOME  UNUSUAL  CONDITION  OF 
THE  FtETUS. 

Plural  Births,  Treatment  of — Locked  Twins — Conjoined  Twins — Intra-uterine 
Hydrocephalus  :  Its  Dangers,  Diagnosis,  and  Treatment — Other  dropsical  Effu- 
sions— Foetal  Tumors — Excessive  Development  of  Foetus  .....  359 

CHAPTER  XII. 

DEFORMITIES   OF    THE  PELVIS. 

Classification — Causes  of  Pelvic  Deformity — Rickets  and  Osteo-malasia — The 
Equally  enlarged  Pelvis — Tlie  Equally  contracted  Pelvis — The  Undeveloped 
Pelvis — Masculine  or  Funnel-shaped  Pelvis — Contraction  of  Conjugate  Diameter 
of  the  Brim — Figure-of-eight  deformity — Spondylolithesis — Narrowing  of  the 
Oblique  Diameters — Obliquely  contracted  Pelvis — Kyphotic  Pelvis — Robert's 
Pelvis — Deformity  from  old-standing  Hip-joint  disease — Deformity  from  Tumors, 
Fractures,  etc. — Effects  of  Contracted  Pelvis  on  Labor — Risks  to  the  Mother  and 
Child — Mechanism  of  Delivery  in  Head  Presentation  ;  a,  in  Contracted  Brim ; 
b,  in  Generally  contracted  Pelvis — Diagnosis — External  Measurements — Internal 
Measurements — Mode  of  estimating  the  Conjugate  diameter  of  the  brim — Mode 
of  Diagnosing  the  Oblique  Pelvis — Treatment — The  Forceps — Turning — The 
Induction  of  Premature  Labor — Induction  of  Abortion       .....  371 


CHAPTER  XIII. 

HEMORRHAGE  BEFORE  DELIVERY  :    PLACENTA  PRiEVIA. 

Definition — Causes — Symptoms — Soiarces  and  Causes  of  Hemorrhage — Prognosis — 
Treatment  .............  393 


CHAPTER  XIV. 

HEMORRHAGE  FROM  SEPARATION  OF    A  NORMALLY  SITUATED  PLACENTA 

Causes  and  Pathology — Symptoms  and  Diagnosis — Prognosis — Treatment    .  .  405 


CONTENTS.  Xvii 

CHAPTER  XV. 

IIEMORKIIAGE  AFTER  DELIVERY. 

PAUB 

Its  frequency — Generally  a  preventable  accident — Causes — Nature's  method  of 
Controlling  Ilemorrliagt: — Uterine  Contraction — Thrombosis — Secondary  Causes 
of  Hemorrhage — Irregular  Uterine  Contraction — Placental  Adhesions — Consti- 
tutional Predisposition  to  Flooding — Symptoms — Preventive  treatment — Cura- 
tive treatment — Secondary  post-partum  Hemorrliagc — Its  Causes  and  Treatment  408 

CHAPTER  XVI. 

RUPTURE  OF  THE  UTERUS,   ETC. 

Its  Fatality — Seat  of  Rupture — Causes,  predisposing  and  exciting — Symptoms — 
Prognosis — Treatment:  when  the  Foetus  remains  in  Utero ;  when  the  Foetus 
has  escaped  from  the  Uterus — Recapitulation — Lacerations  of  the  vagina — Yesico 
aad  Recto-vaginal  Fistulas — Their  mode  of  Formation — Treatment    .         .         .  426 

CHAPTER  XVII. 

INVERSION  OF  TUE  UTERUS. 

Division  into  Acute  and  Chronic  forms — Description — Symptoms — Diagnosis — 
Mode  of  production — Treatment         ......  .         .  435 


PART    lY. 

OBSTETRIC  OPERATIONS. 


CHAPTER  I. 

INDUCTION  OF  PREMATURE  LABOR. 

History — Objects — May  be  performed  either  on  account  of  the  Mother  or  Child — •. 
Modes  of  Inducing  Labor — Puncture  of  Membranes — Administration  of  Oxyto- 
cics— Means  acting  indirectly  on  the  Uterus — Dilatation  of  Cervix — Separation 
of  Membranes — Vaginal  and  Uterine  douches — Introduction  of  Flexible  Ca- 
theter        ..............  443 

CHAPTER  II. 

TURNING. 
History — Turning  by  External  Manipulation — Object  and  Nature  of  the  Opera- 
tion— Cases  Suitable  for  the  operation — Statistics  and  Dangers — Method  of 
performance — Cephalic  Version — Method  of  performance — Podalio  Version — 
Position  of  Patient — Administration  of  Anaesthetics — Period  when  the  opera- 
tion should  be  undertaken — Choice  of  Hand  to  be  used — Turning  by  Bi-polar 
method — Turning  when  the  Hand  is  introduced  into  the  Uterus — Turning  in 
Abdomino-anterior  Positions — Difficult  cases  of  Arm  Presentation  .  .  .  449 
2 


XVlll  CONTENTS. 

CHAPTER  III. 

THE  FORCEPS. 

PAGE 

Frequent  use  of  the  Forceps  in  Modern  practice — Description  of  the  Instrument — 
Tlie  yiiort  Forceps — Its  Varieties — The  Long  Forceps — Suitable  to  all  cases 
alike — Action  of  the  Instrument^ — Its  power  as  a  Tractor,  Lever,  and  Compres- 
sor— .Preliminary  considerations  before  operation — Use  of  Anaesthetics — De- 
scription of  the  Operation — Low  Forceps  Oj)eration — High  Forceps  Operation — 
Possible  Dangers  of  Forceps  Delivery — Possible  Risks  to  the  Child  .         .         .  465 

CHAPTER  IV. 

THE  VECTIS THE  FILLET. 

Nature  of  the  Vectis — Its  use  as  a  Lever  or  Tractor — Cases  in  which  it  is  appli- 
cable— Its  use  as  a  Rectifier  of  Malpositions — The  Fillet — Nature  of  the  Instru- 
ment— Objection  to  its  use         ..........  489 

CHAPTER  V. 

OPERATIONS  INVOLVING  THE  DESTRUCTION  OF  THE  FGETUS. 
Their  Antiquity  and  History — Division  of  Subject — Nature  of  Instruments  em- 
ployed—  Perforator — Crotchet — Craniotomy  Forceps — Cephalotribe — Forceps- 
saw — Ecraseur — Cases  requiring  Craniotomy — Method  of  Perforation — Extrac- 
tion of  the  Head — Comparative  merits  of  Cephalotripsy  and  Craniotomy — 
Extraction  by  the  Craniotomy  Forceps — Extraction  of  the  Body— Embryotomy — 
Decapitation  and  Evisceration  ..........  491 

CHAPTER  VI. 

THE  CiESAREAN  SECTION SYMPHYSEOTOMY  AND  LAPARO-ELYTROTOMY. 

History  of  the  Operation — Statistics — Results  to  Mother  and  Child — Causes  re- 
quiring the  Operation — Post-mortem  Csesarean  Section — Causes  of  Death  after 
the  Caesarean  Section — Peliminary  Preparations — Description  of  the  Operation 
— Subsequent  Management — Substitutes  for  the  Caesarean  Section — Symphyse- 
otomy— Laparo-elytrotomy         .  .         .  ...         .         .  .         .  .  506 

CHAPTER  VII. 

LAPARO-ELYTROTOMY. 

History — Nature  of  the  Operation — Advantages  over  the  Csesarean  Section — 
Cases  suitable  for  the  operation — Anatomy  of  the  parts  concerned  in  the  opera- 
tion— Method  of  performance — Subsequent  treatment        .....  525 

CHAPTER  VIII. 

THE  TRANSFUSION  OF  BLOOD. 

History — Nature  and  Object  of  the  Operation — Use  of  Blood  taken  from  the  Lower 
Animals — Difficulties  from  Coagulation  of  Fibrine — Modes  of  Obviating  them — 
Immediate  Transfusion — Addition  of  Chemical  Agents  to  prevent  Coagulation — 
Defibrination  of  the  Blood — Statistical  Results — Possible  Dangers  of  the  Opera- 
tion— Cases  suitable  for  Transfusion — Description  of  the  Operation — Effects  of 
Successful  Transfusion — Secondary  Effects  of  Transfusion         ....  530 


CONTENTS.  XIX 

PART   Y. 

THE  PUERPERAL  STATE. 


CHAPTER  I. 

THE  PUERPERAL  STATE  AXD  ITS  MANAGE:MENT. 

PAGE 

Importance  of  Studying  the  Puerperal  State — The  Mortality  of  Childbirth — Alte- 
rations in  the  Blood  after  Delivery — Condition  after  Delivery — Nervous  Shock 
— Fall  of  the  Pulse — The  Secretions  and  Excretions — Secretion  of  Milk — 
Changes  in  the  Uterus  after  Delivery — The  Lochia — The  After-pains— Manage- 
ment of  Women  after  Delivery — Treatment  of  Severe  After-pains — Diet  and 
Regimen    ..............  540 

CHAPTER  II. 

MANAGEMENT  OF  THE  INFANT,  LACTATION,  ETC. 

Commencement  of  Respiration  after  the  Birth  of  the  Child — Apparent  Death  of 
the  new-born  Child — Its  Treatment — Washing  and  Dressing  the  Child — Ap- 
plication of  the  Child  to  the  Breast — The  Colostrum  and  its  Pi'operties — Secre- 
tion of  Milk — Importance  of  Nursing — Selection  of  a  Wet-nurse — Management 
of  Lactation — Diet  and  Regimen  of  Nursing  Women — Period  of  Weaning — 
Disorders  of  Lactation — Means  of  Arresting  the  Secretion  of  Milk — Defective 
Secretion  of  Milk — Depressed  Nipples — Fissures  and  Excoriations  of  the  Nipples 
— Excessive  Flow  of  Milk — Mammary  Abscess — Hand-feeding- — Causes  of  Mor- 
tality in  Hand-feeding — Various  kinds  of  Milk — Method  of  Hand-feeding         .  551 

CHAPTER  III. 

PUERPERAL  ECLAMPSIA. 

Its  Doubtful  Etiology — Premonitory  Symptoms — Symjotoms  of  the  Attack — Con- 
dition between  the  Attacks — Relation  of  the  Attacks  to  Labor — Results  to 
Mother  and  Child — Pathology — Treatment — Obstetric  Management  .         .568 

CHAPTER  IV. 

PUERPERAL  INSANITY. 

Classification — Proportion  of  Various  forms — Insanity  of  Pregnancy — Predispos- 
ing Causes — Period  of  Pregnancy  at  which  it  occurs — Type  of  Insanity — 
Prognosis — Transient  Mania  during  Delivery — Puerperal  Insanity  (Proper) — 
Type  of  Insanity — Causes — Theory  of  its  dependence  on  a  Morbid  State  of  the 
Blood — Objections  to  the  theory — Prognosis — Post-mortem  signs — Duration — 
Insanity  of  Lactation — Type — Symptoms — Of  Mania — Of  Melancholia — Treat- 
ment— Question  of  Removal  to  Asylum — Treatment  during  Convalescence         .  577 


XX  CONTENTS. 

CHAPTER  V. 

PUERPERAL  SEPTICEMIA. 

PAGE 

t)iiforences  of  opinion — Confusion  from  this  cause — Modern  view  of  this  Disease — 
History — Its  Mortality  in  Lying-in  Hospitals — Numerous  Theories  as  to  its 
Nature — Theory  of  Local  Origin — Theory  of  an  Essential  Zymotic  Fever — 
Theory  of  its  identity  with  Surgical  Septicaemia — Nature  of  this  view — 
Channels  through  which  Septic  Matter  may  be  absorbed — Character  and  Origin 
of  Septic  Matter  often  obscure — Division  into  Auto-genetic  and  Hetero-genetic 
cases — Sources  of  Self-infection— Sources  of  Hetero-genetic  Infection — Iniluence 
of  Cadaveric  Poison — Infection  from  Erysipelas — Infection  from  other  Zymotic 
Diseases — Contagion  from  other  Puerperal  Patients — Mode  in  which  the  Poison 
may  be  conveyed  to  the  Patient — Conduct  of  the  Practitioner  in  relation  to  the 
Disease — Nature  of  the  Septic  Poison — Local  changes  resulting  from  the  ab- 
sorption of  Septic  Material — Channels  through  which  Systemic  Infection  is 
produced — Pathological  Phenomena  observed  after  general  Blood  Infection — 
Four  principal  Types  of  Pathological  Change — Intense  cases  without  marked 
Post-mortem  Signs — Cases  characterized  by  Inflammation  of  the  Serous  Mem- 
branes— Cases  characterized  by  the  impaction  of  Infected  Emboli,  and  Secondary 
Inflammation  and  Abscess — Description  of  the  Disease — Duration — Varieties  of 
Symptoms  in  dilferent  cases — Symptoms  of  Local  Complications — Treatment     .  589 

CHAPTER  VI. 

PUERPERAL  VENOUS  THROMBOSIS  AND  EMBOLISM. 

Puerperal  Thrombosis  and  its  Results — Conditions  which  favor  Thrombosis — Con- 
ditions whicli  favor  Coagulation  in  the  Puerperal  State — Distinction  between 
Thrombosis  and  Embolism — Is  primary  Thrombosis  of  the  Pulmonary  Arteries 
possible  ? — History — Symptoms  of  Pulmonary  Obstruction — Is  recovery  pos- 
sible ? — Causes  of  Death — Post-mortem  appearances — Treatment       .         .  .  613 

CHAPTER  VII. 

PUERPERAL  ARTERIAL  THROMBOSIS  AND  EMBOLISM. 
Causes — Symptoms — Treatment    ..........   624 

CHAPTER  VIII. 

OTHER  CAUSES  OP  SUDDEN  DEATH  DURING  LABOR  AND  THE  PUERPERAL 

STATE. 

Organic  and  Functional  causes — Idiopathic  Asphyxia — Pulmonary  Apoplexy — 
Cerebral  Apoplexy — Syncope — Shook  and  Exhaustion — Entrance  of  Air  into 
the  Veins 626 

CHAPTER  IX. 

PERIPHERAL  VENOUS  THROMBOSIS  (SYN.  :  CRURAL  PHLEBITIS PHLEGMASIA 

DOLENS ANASARCA  SEROSA CEDEMA  LACTEUM WHITE  LEG,  ETC) 

Nature — Symptoms — History  and  Pathology — Anatomical  form  of  the  Thrombi 
in  the  Veins — Detachment  of  Emboli — Treatment     ......  629 


CONTENTS.  XXI 

CHAPTER  X. 

PELVIC   CELLULITIS  AND  PELVIC  PERITONITIS. 

PAOE 

Two  Forms  of  Disease — Variety  of  Nomenclature — Importance  of  Differential 
Diagnosis — Etiology — Connection  with  ScpticEemia — Seat  of  Inflammation — 
Relative  Frequency  of  the  two  forms  of  Disease — Symptomatology — Results  of 
Physical  Examination — Terminations — Prognosis — Treatment  .         .         .  63(J 

INDEX 645 

2* 


ILLUSTRATIONS. 


Section  of  a  Frozen  Body  in  the  last  months  of  Pregnancy  (afti;r  Braunc).  Illus- 
trating the  Relations  of  the  uterus  to  the  surrounding  Parts,  and  the  attitude 
of  the  Foetus,  which  is  lying  in  the  second  Cranial  Position.  .         .      Plate  I. 

Section  of  a  Frozen  Body  at  the  termination  of  the  first  stage  of  Labor  (after 
Braune).  The  bag  of  membranes  is  still  unbroken,  the  cervix  is  fully  dilated, 
and  the  head  (in  the  second  position)  is  in  the  pelvic  cavity         .         .    Plate  II. 

FIG.  PAQR 

1.  Os  innominatum  ............  26 

2.  Sacrum  and  Coccyx       ...........  27 

3.  Section  of  Pelvis  and  heads  of  Thigh-bones,  showing  the  Suspensory  Action 

of  the  Sacro-iliac  Ligaments.     (After  Wood.)            .....  29 

4.  Outlet  of  Pelvis 32 

5.  The  Female  Pelvis 32 

6.  The  Male  Pelvis 33 

7.  Brim  of  Pelvis,  showing  Antero-posterior,  Oblique,  and  Conjugate  Diameters  34 

8.  Transverse  section  of  Pelvis,  showing  the  Diameters    .....  34 

9.  Planes  of  the  Pelvis,  with  Horizon 36 

10.  Axes  of  the  Pelvis 37 

11.  Representing  general  Axis  of  the  Parturient  Canal,  including  the  Uterine 

Cavity  and  Soft  Parts 38 

12.  Side  view  of  Pelvis 38 

13.  Pelvis  of  a  Child 39 

14.  Vascular  supply  of  Vulva.      (After  Kobelt.)         ......  45 

15.  Longitudinal  section  of  Body,  showing  Relation  of  Generative  Organs           .  46 

16.  Transverse  section  of  Body,  showing  Relations  of  the  Fundus  Uteri     .         .  48 

17.  Transverse  section  of  Uterus         .........  49 

18.  Uterus  and  Appendages  in  an  Infant    ........  49 

19.  Portion  of  Interior  of  Cervix.     (Enlarged  nine  diameters.)           ...  51 

20.  Muscular  Fibres  of  unimpregnated  Uterus.     (After  Farre.)          ...  52 

21.  Developed  Muscular  Fibres  from  the  Gravid  Uterus.     (After  Wagner.)          .  52 

22.  Lining  Membrane  of  Uterus,  showing  network  of  Capillaries  and  orifices  of 

Uterine  Glands.     (After  Farre.)        ........  54 

23.  The  Course  of  the  Glands  in  the  fully  developed  Mucous  Membrane  of  the 

Uterus.     (After  Williams.) 54 

24.  Villi  of  Os  Uteri  stripped  of  Epithelium 55 

25.  Villi  of  Uterus,  covered  with  Pavement  Epithelium  and  containing  Looped 

Vessels.      (After  Tyler  Smith  and  Hassall.) 56 

26.  Bifid  Uterus.     (After  Farre.)        .         . ' 58 

[27.  Partitioned  Uterus 59] 

28.  Adult  Parovarium,  Ovary,  and  Fallopian  Tube.     (After  Kobelt.)          .         .  61 

29.  Posterior  view  of  Muscular  and  Vascular  arrangements.     (After  Rouget.)  .  62 

(  xxiii ) 


XXIV  ILLUSTRATIONS. 

Fia.  PAGE 

30.  Fallopian  Tube  laid  open.     (After  Richard.) 64 

31.  Ovary  enlarged  under  Menstrual  Nisus         .......  65 

32.  Longitudinal  Section  of  Adult  Ovary.     (After  Farre.)  ...  .66 

33.  Section  through  the  cortical  part  of  the  Ovary.     (After  Turner.)          .         .  67 

34.  Vertical  Section  through  the  Ovary  of  the  Human  Foetus.     (After  Foulis.)  68 

35.  Diagrammatic  Section  of  Graafian  Follicle    .......  69 

36.  Bulb  of  Ovary 70 

37.  Mammary  Gland 71 

38.  Section  of  Ovary,  Showing  Corpus  Luteum  three  weeks  after  Menstruation. 

(After  Dalton.) 75 

39.  Corpus  Luteum  at  the  fourth  month  of  Pregnancy.      (After  Dalton,)    .         .  76 

40.  Corpus  Luteum  of  Pregnancy  at  Term.     (After  Dalton.)      ....  76 

41.  Sperm  Cells  and  Nuclei 86 

42.  Ovum  of  Rabbits  containing  Spermatozoa     .......  88 

43.  Formation  of  the  "  Polar  Globule" 90 

44.  Segmentation  of  the  Yelk 90 

45.  Formation  of  the  Blastodermic  Membrane.      (After  .Joulin.)           ...  91 

46.  Aborted  Ovum  (of  about  forty  days),  showing  the  Triangular  Shape  of  the 

Decidua  (which  is  laid  open),  and  the  Aperture  of  the  Fallopian  Tube. 

(After  Coste.) 93 

47.  ^ 

48.  >  Formation  of  the  Decidua.     (After  Dalton.)      ......  94 

49.  ) 

50.  An  Ovum  removed  from  the  Uterus,  and  part  of  the  Decidua  Vera  cut  away. 

(After  Coste.) 94 

51.  Diagram  of  Area  Germinativa,  showing  the  primitive  trace  and  Area  Pel- 

lucida 96 

52.  Development  of  the  Amnion          .........  97 

53.  Development  of  the  Umbilical  Vesicle  and  Amnion 98 

54.  An  Embryo  of  about  twenty-five  days  laid  open.     (After  Coste.)          .         .  98 

55.  Development  of  the  Chorion         .........  99 

56.  Placental  Villus,  greatly  magnified.     (After  Joulin.)  .....  104 

57.  Terminal  Villus  of  Foetal  Tuft,  minutely  injected.     (After  Farre.)       .         .  105 

58.  Diagram  rejjresenting  a  Vertical  Section  of  the  Placenta.     (After  Dalton.)  105 

59.  Diagram  illustrating  the  Mode  in  which  a  Placental  Villus  derives  a  Cover- 

ing from  the  Vascular  System  of  the  Mother.      (After  Priestley.)      .         .  106 

60.  The  Extremity  of  a  Placental  Villus.     (After  Goodsir.)         .         .         .         .106 

61.  Anterior  and  Posterior  Fontanelles 113 

62.  Bi-parietal  diameter.  Sagittal  and  Lambdoidal  Sutures,  with  Posterior  Fon- 

tanelle      .............  113 

63.  Diameters  of  the  Foetal  Skull 114 

64.  Mode  of  ascertaining  the  Position  of  the  Foetus  by  Palpation         .         .         .  116 

65.  Diagram  illustrating  the  Eff"ect  of  Gravity  on  the  Foetus.     (After  Duncan.)  118 

66.  Illustrating  the  greater  Mobility  of  the  Foetus  and  the  larger  relative  amount 

of  Liquor  Amnii  in  Early  Pregnancy.      (After  Duncan.)            •         •         •  118 

67.  Diagram  of  Foetal  Heart.     (After  Dalton.) 122 

68.  Diagram  of  Heart  of  Infant.     (After  Dalton.) 123 

69.  Size  of  Uterus  at  various  Periods  of  Pregnancy 126 

70.  ^ 

71.  (   Supposed  Shortening  of  the  Cervix  at  the  third,  sixth,  eighth,  and  ninth 

72.  I       months  of  Pregnancy,  as  figured  in  Obstetric  works      .         .         .         .129 

73.  J 


ILLUSTRATIONS. 


XXV 


pra. 

74. 

75. 
7(J. 

77. 

78. 
79. 

80. 
81. 

82. 
83. 

84. 
85. 
86. 
87. 


90. 

91. 

92. 

93. 

94. 

95. 

9G. 

97. 

98. 

99. 
100. 
101. 
102. 
103. 
104. 
105. 
106. 
107. 
108. 
109. 
110. 
111. 

112. 
113. 
114. 
115. 
116. 


Cervix  of  a  Woman   Dying   in  the   eiglitli  Montli  of  Pregnancy.      (After 

Duncan.)  ••••........ 

Aj:>pearance  of  the  Areola  in  Pregnancy       ....... 

Illustrating  the  Cavity  between  the  Decidua  Vera  and  the  Decidua  lieflexa 

during  the  early  Months  of  Pregnancy.      (After  Coste.) 
Tubal  Pregnancy,  with  the  Corpus  Luteum  iji  the  Ovary  of  the  opposite 

side  ••••••...,,., 

Tubal  Pregnancy.     (From  a  specimen  in  the  Museum  of  King's  College.)   . 
Extra-uterine   Pregnancy  at  term  of  the   Tubo-Ovarian  Variety.     (After 

a  case  of  Dr.  A.  Sibley  Campbell's.)         ....... 

Uterus  and  Foetus  in  a  case  of  Abdominal  Pregnancy  .... 

Lithopcedion.     (From  a  preparation  in  the  Museum  of  the  Pvoyal  College  of 

Surgeons.)        •••......... 

Contents  of  the  Cyst  in  Dr.  Oldham's  case  of  Missed  Labor 
Hypertrophied  Decidua  laid  open,  with  the  Ovum  attached  to  its  Fundal 

Portion.     (After  Duncan.)        ......... 

Imperfectly  developed  Decidua  Vera,  with  the  Ovum.     (After  Duncan.)     . 
Hydatiform  Degeneration  of  the  Chorion     ....... 

Double  Placenta,  with  Single  Cord      ........ 

Fatty  Degeneration  of  the  Placenta     ........ 

Knots  in  the  Umbilical  Cord  ........ 

Intra-uterine  Amputation  of  both  Arms  and  Legs        ..... 

An  apoplectic  Ovum,  with  Blood  effused  in  masses  under  the  Foetal  Surface 

of  the  Membranes    ........... 

Blighted  Ovum,  with  Fleshy  Degeneration  of  the  Membranes     . 
Mode  in  which  the  Placenta  is  Naturally  Expelled.     (After  Duncan.) 
Attitude  of  Child  in  first  position.     (After  Hodge.)     ..... 

First  Position  :  Movement  of  Flexion  ....... 

First  Position  :  Occiput  in  Cavity  of  Pelvis.     (After  Hodge.) 
First  Position  :  Occiput  at  Outlet  of  Pelvis.     (After  Hodge.) 
First  Position  :  Head  Delivered.      (After  Hodge.)         ..... 

External  Rotation  of  Head  in  first  position.     (After  Hodge.) 

Third  Position  of  Occiput  at  Brim  of  Pelvis 

Fourth  Position  of  Occiput  at  Pelvic  Brim 

Examination  during  the  First  Stage  of  Labor 

Mode  of  effecting  Relaxation  of  the  Perineum 

Usual  Method  of  Removing  the  Placenta  by  Traction 

Illustrating  Expression  of  the  Placenta 

First,  or  left  Sacro-cotyloid  position  of  the  Breech 

Passage  of  the  Shoulders  and  partial  Rotation  of  tlu 

Descent  of  the  Head    ...... 

Second  position  in  Face  Presentation  . 

Rotation  Forwards  of  Chin  .... 

Passage  of  the  Head  through  the  External  Parts  in  Face  Presentation 
Illustrating  the  position  of  the  Head  when  Forward  Rotation  of  the  Chin 

does  not  take  jjlace 
Dorso-anterior  Presentation  of  the  Arm 
Dorso-posterior  Presentation  of  the  Arm 
Commencing  Spontaneous  Evolution   . 
Spontaneous  Evolution  further  Advanced 
Dorsal  Displacement  of  the  Arm 


on  the  Cord 


Thorax 


129 
139 

lOG 

1G9 
170 

172 
179 

180 
180 

219 
219 
221 
225 

226 

227 
232 

238 
238 
259 
264 
265 
267 
267 
269 
269 
270 
273 
278 
282 
285 
286 
296 
297 
298 
306 
308 
309 

309 
318 
318 
323 
324 
326 


XXVI  ILLUSTRATIONS. 

FIO.  PAGE 

117.  Dorsal  Displacement  of  the  Arm  in  Footling  Presentations.   (After  Barnes.)  326 

118.  Prolapse  of  the  Umbilical  Cord 327 

.  329 

.  331 

.  354 

.  359 


119.  Postural  Treatment  of  Prolapse  of  the  Cord 

120.  Braun's  Apparatus  for  Replacing  the  Cord 

121.  Labor  complicated  by  Ovarian  Tumor 

122.  Twin  Pregnancy,  Breech  and  Head  presenting    . 

123.  Head  Locking,  both  Children  presenting  Head  first.     (After  Barnes.)  .  361 

124.  Head  Locking,  first   Child  coming  Feet  first :    Impaction  of   Heads  from 

wedging  in  Brim.     (After  Barnes.) 362 

125.  Labor  impeded  by  Hydrocejphalus 367 

126.  Adult  Pelvis  retaining  its  Infantile  Type 375 

127.  Rickety  Pelvis,  with  backward  depression  of  Symphysis  Pubis  .         .  376 

128.  Flatness  of  Sacrum,  with  narrowing  of  Pelvic  Cavity  ....  377 

129.  Pelvis  deformed  by  Spondylolithesis.      (After  Killian.)         ....  377 

130.  Osteo-malacic  Pelvis    . 378 

131.  Extreme  degree  of  Osteo-malacic  Deformity  ......  379 

132.  Obliquely  Contracted  Pelvis,     (After  Duncan.) 379 

133.  Robert's,  or  double  obliquely  Contracted  Pelvis  .....  380 

134.  Bony  Growth  from  Sacrum  obstructing  the  Pelvic  Cavity    ....  381 

135.  Greenhalgh's  Pelvimeter      ..........  386 

136.  Section  of  Foetal  Cranium,  showing  its  Conical  Form  ....  389 

137.  Showing  the  greater  Breadth  of  the  biparietal  Diameter  of  the  FoBtal  Cra- 

nium.    (After  Simpson.)  .........  389 

138.  Showing  the  greater  Space  for  the  biparietal  Diameter  in  certain  Cases  of 

Deformity.     (After  Simpson.)  ........  390 

139.  Irregular  Contraction  of  the  Uterus,  with  Encystment  of  the  Placenta        .  412 

140.  Partial  Inversion  of  the  Fundus  ........  436 

141.  Illustrating  the  Commencement  of  Inversion  at  the  Cervix.  (After  Duncan.)  439 

142.  Barnes's  Bag  for  Dilating  the  Cervix 446 

143.  First  Stage  of  Bi-polar  Version 456 

144.  Second  Stage  of  Bi-polar  Version 457 

145.  Third  Stage  of  Bi-polar  Version 457 

146.  Fourth  Stage  of  Bi-polar  Version 458 

147.  Seizure  of  the  Feet  when  the  Hand  is  introduced  into  the  Uterus        .  .  460 

148.  Drawing  down  of  the  Feet  and  Completion  of  Version         ....  461 

149.  Showing  the  Completion  of  Version.      (After  Barnes.)         ....  462 

150.  Showing  the  Use  of  the  Right  Hand  in  Abdomino-anterior  jDositions  .         .  463 

151.  Denman's  Short  Forceps      ..........  466 

152.  Zeigler's  Forceps 467 

153.  Sim^DSon's  Forceps 468 

154.  Tarnier's  Forceps 469 

155.  Position  of  Patient  for  Forceps   Delivery,  and  Mode  of  Introducing  the 

Lower  Blade    ............  473 

156.  Introduction  of  the  Upper  Blade 4'J5 

157.  Forceps  in  position  ;    Traction  in  the  Axis  of  the  Brim,  downwards  and 

backwards        ............  476 

158.  Last  Stage  of  Extraction  ;    the  Handles  of  the  Forceps  turned  upwards 

towards  the  Mother's  Abdomen 477 

[159.  Hodge  Forceps 481] 

[160.  Wallace     "  482] 

[161.  Davis         "  482] 


ILLUSTRATIONS.  XXVU 

'Fia.  PAGE 

[162.  Elliot  Forceps 483] 

[1G3.   Sawyer     " 484] 

[164.  Application  of  ForceiJS  at  Inferior  Strait  .......  485] 

[165.  Application  of  Forceps  in  the  Head  at  Sujjerior  Strait,  the  left  Blade  held 

in  place  by  an  Assistant 487] 

[166.  Direction  of  Forceps  as  Head  is  being  delivered 488] 

167.  Vectis  with  Hinged  Handle 489 

168.  Wilmot's  Fillet 490 

169.  ^ 

170.  >  Various  forms  of  Perforators .     493 

171.  ^ 

172  and  173.  Crotchets 493 

174.  Craniotomy  Forceps     ...........  494 

175.  Simpson's  Cranioclast          ..........  494 

176.  Hicks's  Cephalotribe 496 

177.  Perforation  of  the  Skull      .         .         . 499 

178.  Foetal  Head  crushed  by  the  Cephalotrilje 502 

[179.  Straight  Craniotomy  Forceps 503] 

[180.  Curved            "                  " 503] 

181.  Method  of  Transfusion  by  Aveling's  Apparatus  .....     537 

182.  Section  of  a  Uterine  Sinus  from  the  Placental  Site  nine  weeks  after  aelivery. 

(After  Williams.) 545 

183.  Hayes's  Tube  for  Intra-uterine  Injections 608 


P  L  A  T  E     I . 


stomach '• 


Oo  Pubis 


Clitoris 


rortio 
Vagiualis 


Vagina 


^T-  Kectum 


Sectiott  of  a  Frozen  Body  in  tlie  last  month  of  Pregnancy  (after  Braune),  illustrating  the  Relations  of  the 
Uterus  to  the  surrounding  parts,  and  the  Attitude  of  the  Foetus,  which  is  lying  in  the  Second  Cranial 
PositionT 


1^  L  A  T  E     II 


Section  of  a  Frozen  Body  at  the  termination  of  the  First  Stage  of  Labor  (after  Braune).  The  Bag  of  Mem- 
branes is  still  unbroken,  the  Cervix  is  fully  dilated,  and  the  Head  (in  the  second  position)  is  in  the  Pelvic 
Cavity. 


THE 


SCIENCE  AND  PRACTICE 


MIDWIFERY. 


PART  I. 

ANATOMY  AND  PHYSIOLOGY  OF  THE  ORGANS  CONCERNED 
IN  PARTURITION. 


CHAPTEE   I. 

ANATOMY  OF  THE  PELVIS. 

The  pelvis  is  the  bony  basin  sitnated  between  the  trunk  and  the 
lower  extremities.  To  the  obstetrician  its  study  is  of  paramount 
importance,  for  it  not  only  contains,  in  the  unimpregnated  state,  all 
the  organs  connected  with  the  function  of  reproduction,  but  through 
its  cavity  the  foetus  has  to  pass  in  the  process  of  parturition.  An 
accurate  knowledge,  therefore,  of  its  anatomical  formation  may  be 
said  to  be  the  very  alphabet  of  obstetrics,  without  which  no  one  can 
practise  midwifery,  either  with  satisfaction  to  himself,  or  safety  to 
his  patient. 

In  a  treatise  on  obstetrics,  however,  any  detailed  account  of  the 
purely  descriptive  anatomy  of  the  pelvis  would  be  out  of  place.  A 
knowledge  of  that  must  be  taken  for  granted,  and  it  is  only  necessary 
to  refer  to  those  points  which  have  a  more  or  less  direct  bearing  on 
the  study  of  its  obstetrical  relations. 

The  pelvis  is  formed  of  four  bones.  On  either  side  are  the  ossa 
innominata^  joined  together  by  the  sacriim  ;  to  the  inferior  extremity 
of  the  sacrum  is  attached  the  coccyx^  which  is,  in  fact,  its  continuation. 

The  OS  innominatura  (Fig.  1)  is  an  irregularly  shaped  bone  origi- 
nally formed  of  three  distinct  portions,  the  ilium^  the  ischium^  and 
the  puhes^  which  remain  separated  from  each  other  up  to  and  beyond 
the  period  of  puberty.  They  are  united  at  the  acetabulum  by  a 
Y-shaped  cartilaginous  junction,  which  does  not,  as  a  rule,  become 
ossified  until  about  the  twentieth  year.  The  consequence  is  that  the 
3  (25) 


26 


ORGANS    CONCERNED    IN    PARTURITION. 


pelvis,  during  the  period  of  growth,  is  subject  to  tlie  action  of  various 
mechanical  influences  to  a  far  greater  extent  than  in  adult  life  ;  and 
these,  as  we  shall  presently  see,  have  an  important  effect  in  deter- 
mining the  form  of  the  bones.  The  external  surface  and  borders  of 
the  OS  innominatum  are  chiefly  of  obstetric  interest  from  giving 
attachment  to  muscles,  many  of  which  have  an  important  accessor}^ 
influence  on  parturition,  such  as  the  muscles  forming  the  abdominal 
wall,  which  are  attached  to  its  crest,  and  those  closing  its  outlet  and 

Fig,  1. 


Oa  Innominatum. 

forming  the  perineum,  which  are  attached  to  the  tuberosity  of  the 
ischium.  On  the  anterior  and  posterior  extremities  of  the  crest  of 
the  ilium  are  two  prominences  (the  anterior  and  posterior  spinous 
processes)  which  are  points  from  which  certain  measurements  are 
sometimes  taken.  The  internal  surface  of  the  upper  fan-shaped 
portion  of  the  os  innominatum  gives  attachment  to  the  iliacus  muscle, 
and  contributes  to  the  support  of  the  abdominal  contents  ;  along  with 
its  fellow  of  the  opposite  side  it  forms  the  false  pelvis.  The  false  is 
separated  from  the  true  pelvis  by  the  ilio-pectineal  line,  which,  with 
the  upper  margin  of  the  sacrum,  forms  the  brim  of  the  pelvis.  This 
is  of  especial  obstetric  importance,  as  it  is  the  first  part  of  the  pelv^ic 
cavity  through  which  the  child  passes,  and  that  in  which  osseous 
deformities  are  most  often  met  with.  At  one  portion  of  the  ilio- 
pectineal  line,  corresponding  with  the  junction  of  the  ilium  and  pubes, 
is  situated  a  prominence,  which  is  known  as  the  ilio-pectineal  eminence. 

Internal  Surface. — The  internal  smooth  surface  of  the  innominate 
bone  below  the  linea  ilio-pectinea  forms  the  greater  portion  of  the 
pelvis  proper.  In  front,  with  the  corresponding  portions  of  the 
opposite  bone,  it  forms  the  arch  of  the  pubes,  under  which  the  head 
of  the  child  passes  in  labor. 

Behind  this  we  observe  the  oval  obturator  foramen,  and  below  that 
the  tuberosity  and  spine  of  the  ischium,  the  latter  separating  the  great 
and  lesser  sciatic  notches,  and  giving  attachment  to  ligaments  of  im- 


ANATOMY    OF    THE    PELVIS. 


2T 


Fig.  2. 


portancc.  The  rough  articulating  surface  posteriorly,  by  which  the 
junction  with  the  sacrum  is  effected,  may  be  noted,  and  above  this 
the  prominence  to  which  the  powerful  ligaments  joining  the  sacrum 
and  OS  innominatum  are  attached. 

The  sacrum  (Fig.  2)  is  a  triangular  and  somewhat  spongy  bone 
forming  the  continuation  of  the  spinal  column,  and  binding  together 
the  ossa  innominata.  It  is  originally 
composed  of  five  spparate  portions,  anal- 
ogous to  the  vertebrai,  which  ossify  and 
unite  about  the  period  of  puberty,  leaving 
on  its  internal  surface  four  prominent 
ridges  at  the  points  of  junction.  The 
upper  of  these  is  sometimes  so  well 
marked  as  to  be  mistaken  on  vaginal 
examination,  for  the  promontory  of  the 
sacrum  itself. 

The  base  of  the  sacrum  is  about  4| 
inches  in  width,  and  its  sides  rapidly  ap- 
proximate until  they  nearly  meet  at  its 
apex,  giving  the  whole  bone  a  triangular 
or  wedge  shape.  The  anterior  and  pos- 
terior surfaces  also  approximate  in  the 
same  way,  so  that  the  bone  is  much 
thicker  at  the  base  than  at  the  apex. 
The  sacrum,  in  the  erect  position  of  the 
body,  is  directed  from  above  downwards  and  from  before  backwards. 
At  its  upper  edge  it  is  joined,  the  lumbo-sacral  cartilage  intervening, 
with  the  fifth  lumbar  vertebra.  The  point  of  junction,  called  the 
promontory  of  the  sacrum,  is  of  great  importance,  as  on  its  undue 
projection  many  deformities  of  the  brim  of  the  pelvis  depend.  The 
anterior  surface  of  the  bone  is  concave,  and  forms  the  curve  of  the 
sacrum;  more  marked  in  some  cases  than  in  others.  There  is  also 
more  or  less  concavity  from  side  to  side.  On  it  we  observe  four 
apertures  on  each  side,  the  intervertebral  foramina  giving  exit  to 
nerves.  The  posterior  surface  is  convex,  rough  and  irregular  for  the 
attachment  of  ligaments  and  muscles,  and  showing  a  ridge  of  vertical 
prominences,  corresponding  to  the  spinous  processes  of  the  vertebrae. 

Meclianical  Relations  of  the  Sacrum. — The  sacrum  is  generally  de- 
scribed as  forming  a  keystone  to  the  arch  constituted  by  the  pelvic 
bones,  and  transmitting  the  weight  of  the  body,  in  consequence  of  its 
wedge- like  shape,  in  a  direction  which  tends  to  thrust  it  downwards 
and  backwards,  as  if  separating  the  ossa  innominata.  Dr,  Duncan,^ 
however,  has  shown,  from  a  very  careful  consideration  of  its 
mechanical  relations,  that  it  should  rather  be  regarded  as  a  strong 
transverse  beam,  curved  on  its  anterior  surface,  the  extremities  of 
which  are  in  contact  with'the  corresponding  articular  surfaces  of  the 
ossa  innominata.  The  weight  of  the  body  is  thus  transmitted  to  the 
innominate  bones,  and  through  them  to  theacotabula  and.  the  femurs. 


Sacrum  and  Coccyx. 


'  Researches  in  Obstetrics,  p.  G7. 


28  ORGANS    CONCERINED    IN    PARTURITION. 

(Fig,  3.)  There  counter-pressure  is  applied,  and  the  result  is,  as  we 
shall  subsequently  see,  an  iraportaTit  modifying  influence  on  the  de- 
velopment and  shape  of  the  pelvis. 

The  coccyx  (Fig.  2)  is  composed  of  four  small  separate  bones,  which 
eventually  unite  into  one,  but  not  until  late  in  life.  The  uppermost 
of  these  articulates  with  the  apex  of  the  sacrum.  On  its  posterior 
surface  are  tv/o  small  cornua,  which  unite  with  corresponding  points 
at  the  tip  of  the  sacrum.  The  bones  of  the  coccyx  taper  to  a  point. 
To  it  are  attached  various  muscles  which  have  the  effect  of  imparting 
considerable  mobility.  During  labor,  also,  it  yields  to  the  mechanical 
pressure  of  the  presenting  part,  so  as  to  increase  the  antero-posterior 
diameter  of  the  pelvic  outlet  to  the  extent  of  an  inch  or  more. 

Ossification  of  Coccyx. — -If,  through  disease  or  accident,  as  sometimes 
happens,  the  articular  cartilages  of  the  coccyx  become  prematurely 
ossified,  the  enlargement  of  the  pelvic  outlet  during  labor  may  be 
prevented,  and  considerable  difficulty  may  thus  arise.  This  is  most 
apt  to  happen  in  aged  primiparse,  or  in  women  who  have  followed 
sedentary  occupations;  and  not  infrequently,  under  such  circum- 
stances, the  bone  fractures  under  the  pressure  to  which  it  is  subjected 
by  the  presenting  part. 

Pelvic  Articulations. — The  pelvic  bones  are  firmly  joined  together 
by  various  articulations  and  ligaments.  The  latter  are  arranged  so 
as  to  complete  the  canal  through  which  the  foetus  has  to  pass,  and 
which  is  in  great  part  formed  by  the  bones.  On  its  internal  surface, 
where-  the  absence  of  obstruction  is  of  importance,  they  are  every- 
where smooth  ;  while  externally,  where  strength  is  the  desideratum, 
they  are  arranged  in  larger  masses,  so  as  to  unite  the  bones  firmly 
together.  The  pelvic  articulations  have  been  generally  described  as 
symphyses  or  amphiarthrodia,  a  term  which  is  properly  applied  to 
two  articulating  surfaces,  united  by  fibrous  tissue  in  such  a  way  as 
to  prevent  any  sliding  motion.  It  is  certain,  however,  that  this  is 
not  the  case  with  the  joints  of  the  female  pelvis  during  pregnancy 
and  parturition,  Lenoir  found  that  in  22  females,  between  the  ages 
of  18  and  35,  there  was  a  distinct  sliding  motion.  Therefore,  the 
pelvic  articulations  are,  strictly  speaking,  to  be  considered  examples 
of  the  class  of  joints  termed  arthrodia. 

Lumbosacral  Joint. — The  last  lumbar  vertebra  is  united  to  the 
sacrum  by  ligamentous  union  similar  to  that  which  joins  the  vertebrte 
to  each  other.  The  intervening  fibro- cartilage  forms  a  disk,  which 
is  thicker  in  front  than  behind,  and  this,  in  connection  with  a  similar 
peculiarity  of  the  fifth  lumbar  vertebra,  tends  to  increase  the  sloped 
position  of  the  sacrum,  and  the  angle  which  it  forms  with  the  verte- 
bral column.  It  constitutes  the  most  prominent  portion  of  the  pro- 
montory of  the  sacrum,  and  is  the  part  on  which  the  finger  generally 
impinges  in  vaginal  examinations.  The  anterior  common  vertebral 
ligament  passes  over  the  surface  of  the  joints,  and  we  also  find  the 
ligamenta  sub-flava  and  the  inter-spinous  ligaments,  as  in  the  other 
vertebrae.  The  articular  processes  are  joined  together  by  a  fibrous 
capsule,  and  there  is  also  a  peculiar  ligament,  the  lumbo-sacral, 
extending  from  the  transverse  process  of  the  vertebra  on  each  side, 


ANATOMY    OF    THE    PELVIS, 


29 


and  attacliing  itself  to  the  sides  of  the  sacrum  and  the  sacro-iliac 
synchondrosis. 

Ligaments  of  Coccyx. — The  sacrum  is  joined  to  the  coccyx,  and,  in 
some  cases  at  least,  the  separate  bones  of  the  coccyx  to  each  other, 
by  small  cartilaginous  disks  like  that  connecting  the  sacrum  with 
the  last  lumbar  vertebra.  They  are  farther  united  by  anterior  and 
posterior  common  ligaments,  the  latter  being  much  the  thicker  and 
more  marked.  In  the  adult  female  a  synovial  membrane  is  found 
between  the  sacrum  and  coccyx,  and  it  is  supposed  tiiat  this  is  formed 
under  the  influence  of  the  movements  of  the  bones  on  each  other. 

Sacro-iliac  Synchondrosis. — The  opposing  articular  surfaces  of  the 
sacrum  and  ilium  are  each  covered  by  cartilages,  that  of  the  sacrum 
being  the  thickest.  These  are  firmly  united,  but,  in  the  female, 
according  to  Mr.  Wood,^  they  are  always  more  or  less  separated  by 
an  intervening  synovial  membrane.  Posterior  to  these  cartilaginous 
convex  surfaces  there  are  strong  interosseous  ligaments,  passing 
directly  from  bone  to  bone,  filling  up  the  interspace  between  them, 
and  uniting  them  firmly.  There  are  also  accessory  ligaments,  such 
as  the  superior  and  anterior  sacro  iliac,  which  are  of  secondary  con- 
sequence.    The  posterior  sacro-iliac  ligaments,  however,  are  of  great 

Fig,  3. 


Section  of  Pelvis  and  Heads  of  Thish-bones,  showing  the  Suspensory  Action  of  the  Sacro-iliac 
Ligaments.     (After  Wood.) 

obstetric  importance.  They  are  the  very  strong  attachments  which 
unite  the  rough  surfaces  on  the  posterior  iliac  tuberosities  to  the 
posterior  and  lateral  surfaces  of  the  sacrum.  They  pass  obliquely 
downwards  from   the   former   points,  and  suspend,  as  it  were,  the 

'  Todd's  Cyclopaedia  of  Anatomy  and  Physiology,  article  "  Pelvis"  p.  123. 


30  ORGANS    CONCERNED    IN    PARTURITION. 

sacrum  from  them.  According  to  Duncan,  the  sacrum  has  nothing 
to  prevent  its  being  depressed  by  the  weight  of  the  body  but  these 
ligaments,  and  it  is  mainly  through  them  that  the  weight  of  the  body 
is  transmitted  to  the  sacro-cotyloid  beams  and  the  heads  of  the  femur. 

Sacro-sciatic  Ligaments. — The  sacro-sciatic  ligaments  are  instru- 
mental in  completing  the  canal  of  the  pelvis.  The  greater  sacro- 
sciatic  ligament  is  attached  by  a  broad  base  to  the  posterior  spine  of 
the  ilium,  and  to  the  posterior  surfaces  of  the  ilium  and  coccyx.  Its 
fibres  unite  into  a  thick  cord,  cross  each  other  in  an  X-like  manner, 
and  again  expand  at  their  insertion  into  the  tuberosity  of  the  ischium. 
The  lesser  sacro-sciatic  ligament  is  also  attached  with  the  former  to 
the  back  parts  of  the  sacrum  and  coccyx,  its  fibres  passing  to  their 
much  narrower  insertion  at  the  spine  of  the  ischium,  and  converting 
the  sacro-sciatic  notch  into  a  complete  foramen. 

Obturator  Membrane. — The  obturator  membrane  is  the  fibrous 
aponeurosis  that  closes  the  large  obturator  foramen.  Joulin^  supposes 
that,  along  with  the  sacro-sciatic  ligaments,  it  may,  by  yielding  some- 
what to  the  pressure  of  the  foetal  head,  tend  to  prevent  the  contusion 
to  which,  the  soft  parts  would  be  subjected  if  they  were  compressed 
between  two  entirely  osseous  surfaces. 

Symphysis  Pubis. — The  junction  of  the  pubic  bones  in  front  is 
effected  by  means  of  two  oval  plates  of  fibro-cartilage,  attached  to 
each  articular  surface  by  nipple-shaped  projections,  which  fit  into 
corresponding  depressions  in  the  bones.  There  is  a  greater  separa- 
tion between  the  bones  in  front  than  behind,  where  the  numerous 
fibres  of  the  cartilaginous  plates  intersect,  and  unite  the  bones  firmly 
together.  At  the  upper  and  back  part  of  the  articulation  there  is 
an  interspace  between  the  cartilages,  which  is  lined  by  a  delicate 
membrane.  In  pregnancy  this  space  often  increases  in  size,  so  as 
to  extend  even  to  the  front  of  the  joint.  The  juncture  is  further 
strengthened  by  four  ligaments,  the  anterior,  the  posterior,  the  supe- 
rior, and  the  sub-pubic.  Of  these,  the  last  is  the  largest,  connecting 
together  the  pubic  bones  and  forming  the  upper  boundary  of  the 
pubic  arch. 

Movements  of  Pelvic  Jomfe.— The  close  apposition  of  the  bones  of 
the  pelvis  might  not  unreasonably  lead  to  the  supposition  that  no 
movement  took  place  between  its  component  parts;  and  this  is  the 
opinion  which  is  even  yet  held  by  many  anatomists.  It  is  tolerably 
certain,  however,  that  even  in  the  unimpregnated  condition  there  is 
a  certain  amount  of  mobility.  Thus  Zaglas  has  pointed  out^  that  in 
man  there  is  a  movement  in  an  antero-posterior  direction  of  the 
sacro-iliac  joints,  which  has  the  effect,  in  certain  positions  of  the  body, 
of  causing  the  sacrum  to  project  downwards  to  the  extent  of  about 
a  line,  thus  narrowing  the  pelvic  brim,  tilting  up  the  point  of  the 
bone,  and  thereby  enlarging  the  outlet  of  the  pelvis.  This  movement 
seems  habitually  brought  into  play  in  the  act  of  straining  during 
defecation. 

'  Traite  d'AccoucheTnents,  p    11. 

2  Monthly  Journal  of  Med.  Science,  Sept.  1851. 


ANATOMY    OF    THE    PELVIS.  31 

Ohservations  in  the  Lower  Animals. — During  pregnancy  in  some  of 
the  lower  animuls  there  is  a  very  marked  movement  of  the  pelvic 
articulations,  which  materially  facilitates  the  process  of  parturition. 
This,  in  the  case  of  the  guinea-pig  and  cow,  has  been  specially  pointed 
out  by  Dr.  Matthews  Duncan.^  In  the  former,  during  labor,  the 
pelvic  bones  separate  from  each  other  to  the  extent  of  an  inch  or 
more.  In  the  latter  the  movements  are  different,  for  the  symphysis 
pubis  is  fixed  by  bony  anchylosis,  and  is  immovable ;  but  the  sacro- 
iliac joints  become  swollen  during  pregnancy,  and  extensive  move- 
ments in  an  antero-postorior  direction  take  place  in  them,  which 
materially  enlarge  the  pelvic  canal  during-  labor. 

Mode  in  luhich  the  Movements  are  effected. — It  is  extremely  probable 
that  similar  movements  take  place  in  women,  both  in  the  symphysis 
pubis  and  in  the  sacro-iliac  joints,  although  to  a  less  marked  extent. 
These  are  particularly  well  described  by  Dr,  Duncan.  They  seem  to 
consist  chiefly  in  an  elevation  and  depression  of  the  symphysis  pubis, 
either  by  the  ilia  moving  on  the  sacrum,  or  by  the  sacrum  itself 
undergoing  a  forward  movement  on  an  imaginary  transverse  axis 
passing  through  it,  thus  lessening  the  pelvic  brim  to  the  extent  of 
one  or  even  two  lines,  and  increasing,  at  the  same  time,  the  diameter 
of  the  outlet  by  tilting  up  the  apex  of  the  sacrum.  These  movements 
are  only  an  exaggeration  of  those  which  Zaglas  describes  as  occurring 
normally  during  defecation.  The  instinctive  positions  which  the 
parturient  woman  assumes  find  an  explanation  in  these  observations. 
During  the  first  stage  of  labor,  when  the  head  is  passing  through  the 
brim,  she  sits,  or  stands,  or  walks  about,  and  in  these  erect  positions 
the  symphysis  pubis  is  depressed,  and  the  brim  of  the  pelvis  enlarged 
to  its  utmost.  As  the  head  advances  through  the  cavity  of  the 
pelvis,  she  can  no  longer  maintain  her  erect  position,  and  she  lies 
down  and  bends  her  body  forward,  which  has  the  effect  of  causing  a 
nutatory  mption  of  the  sacrum,  with  corresponding  tilting  up  of  its 
apex,  and  an  enlargement  of  the  outlet. 

Alterations  in  the  Pelvic  Joints  during  Pre<jnancy. — These  move- 
ments during  parturition  are  facilitated  by  the  changes  which  are 
known  to  take  place  in  the  pelvic  articulations  during  pregnancy. 
The  ligaments  and  cartilages  become  swollen  and  softened,  and  the 
synovial  membranes  existing  between  the  articulating  surfaces  become 
greatly  augmented  in  size  and  distended  with  fluid.  These  changes 
act  by  forcing  the  bones  apart,  as  the  swelling  of  a  sponge  placed 
between  them  might  do  after  it  had  imbibed  moisture.  The  reality 
of  these  alterations  receives  a  clinical  illustration  from  those  cases, 
which  arc  far  from  uncommon,  in  which  these  changes  are  carried 
to  so  extreme  an  extent,  that  the  power  of  progression  is  materially 
interfered  with  for  a  considerable  time  after  delivery. 

Pelvis  as  a  Whole. — On  looking  at  a  pelvis  as  a  whole,  we  are  at 
once  struck  with  its  division  into  the  true  and  false  pelvis.  The 
latter  portion  (all  that  is  above  the  brim  of  the  pelvis)  is  of  compara- 
tively little  obstetric  importance,  except  in  giving  attachments  to 

1  Researches  in  Obstetrics,  p.  19. 


32 


ORGANS    CONCERNED    IN    PARTURITION. 


the  accessory  muscles  of  parturition,  and  need  not  be  further  con- 
sidered. The  brira  of  the  pelvis  is  a  heart-shaped  opening,  bounded 
by  the  sacrum  behind,  the  linea  ilio-pectinea  on  either  side,  and  the 
symphysis  of  the  pubes  in  front.  All  below  it  forms  the  cavity, 
which  is  bounded  by  the  hollow  of  the  sacrum  behind,  by  the  inner 
surfaces  of  the  innominate  bones  at  the  sides  and  in  front,  and  by  the 
posterior  surface  of  the  symphysis  pubis.  It  is  in  this  part  of  the 
pelvis  that  the  changes  in  direction  which  the  foetal  head  undergoes 

Fig.  4. 


Outlet  of  Pelvis, 

in  labor  are  imparted  to  it.  The  lower  border  of  this  canal,  or 
pelvic  outlet  (Fig.  4),  is  lozenge-shaped,  is  bounded  by  the  ischiatic 
tuberosities  on  either  side,  the  tip  of  the  coccyx  behind,  and  the 
under  surface  of  the  pubic  symphysis  in  front.  Posteriorly  to  the 
tuberosities  of  the  ischia  the  boundaries  of  the  outlet  are  completed 
by  the  sacro-sciatic  ligaments. 

Differences  in  the  two  Sexes. — There  is  a  very  marked  difference 

Fig.  5. 


The  Female  Pelvis. 


between  the  pelvis  in  the  male  and  the  female,  and  the  peculiarities 
of  the  latter  all  tend  to  facilitate  the  process  of  parturition.     In  the 


ANATOMY    OF    THE    PELVIS, 


33 


female  pelvis  (Fig.  5)  all  the  bones  are  liglitcr  in  structure,  and  have 
the  points  for  muscular  attachments  much  less  developed.  The  iliac 
bones  are  more  spread  out,  hence  the  greater  breadth  which  is  ob- 
served in  the  female  figure,  and  the  peculiar  side-to-side  movement 
which  all  females  have  in  walking.  The  tuberosities  of  the  ischia 
are  lighter  in  structure  and  further  apart,  and  the  rami  of  the  pubes 
also  converge  at  a  much  less  acute  angle.  This  greater  breadth  of 
the  pubic  arch  gives  one  of  the  most  easily  appreciable  points  of 

Fig.  G. 


The  Male  Pelvis. 


contrast  between  the  male  and  female  pelvis  ;  the  pubic  arch  in  the 
female  forms  an  angle  of  from  90^  to  100^,  while  in  the  male  (Fig. 
6)  it  averages  from  70^  to  75-^.  The  obturator  foramen  are  more 
triangular  in  shape. 

The  whole  cavity  of  the  female  pelvis  is  wider  and  less  funnel- 
shaped  than  in  the  male,  the  symphysis  pubis  is  not  so  deep,  and,  as 
the  promontory  of  the  sacrum  does  not  project  so  much,  the  shape 
of  the  pelvic  brim  is  more  oval  than  heart-shaped.  These  differences 
between  the  male  and  female  pelves  are  probably  due  to  the  presence 
of  the  female  genital  organs  in  the  true  pelvis,  the  growth  of  which 
increases  its  development  in  width.  In  proof  of  this,  Schroeder  states 
that  in  women  with  congenitally  defective  internal  organs,  and  in 
women  who  have  had  both  ovaries  removed  early  in  life,  the  pelvis 
has  always  more  or  less  of  the  masculine  tvpe. 

Measurements  of  the  Pelvis. — The  measurements  of  the  pelvis  that 
are  of  most  importance  from  an  obstetric  point  of  view,  are  taken 
between  various  points  directly  opposite  to  each  other,  and  are  known 
as  the  diaraeters  of  the  pelvis.  Those  of  the  true  pelvis  are  the  dia- 
meters which  it  is  especially  important  to  fix  in  our  memories,  and 
it  is  customary  to  describe  three  in  works  on  obstetrics— the  antero- 
posterior or  conjugate,  the  oblique,  and  the  transverse — although  of 
course  the  measurements  may  be  taken  at  any  opposing  points  in 
the  circumference  of  the  bones.  The  antero-posterior  (sacro-pubic), 
at  the  brim  (Fig.  7),  is  taken  from  the  upper  part  of  the  posterior 


34 


ORGANS    CONCERNED    IN    PARTURITION. 

Fig.  7. 


Brim  of  Pelvis,  showing  Antero-posterior,  Oblique,  and  Conjugate  Diameters. 


Fig.  8. 


sverse  Section  of  Pelvis,  showing  the 
Diameters. 


surface  of  the  symphysis  pubis  to 
the  centre  of  the  promontor}^  of  the 
sacrum  ;  in  the  cavity,  from  the 
centre  of  the  symphysis  pubis  to  a 
corresponding  point  in  the  body  of 
the  third  piece  of  the  sacrum  ;  and 
at  the  outlet  (coccy- pubic),  from 
the  lower  border  of  the  symphysis 
pubis  to  the  tip  of  the  coccyx. 
The  oblique^  at  the  brim,  is  taken 
from  the  sacro-iliac  joint  on  either 
side  to  a  point  of  the  brim  corres- 
ponding with  the  ilio-pectineal  em- 
inence (that  starting  from  the  right 
sacro-iliac  joint  being  called  the 
right  oblique,  that  from  the  left, 
the  left  oblique) ;  in  the  cavity  a 
similar  measurement  is  made  at  the 
same  level  as  the  conjugate ;  while 
at  the  outlet  an  oblique  diameter  is 
not  usually  measured.  The  trans- 
verse is  taken  at  the  brim,  from  a 
point  midway  between  the  sacro- 
iliac joint  and  the  ilio-pectineal 
eminence  to  a  corresponding  point 
at  the  opposite  side  of  the  brim ; 
in  the  cavity  from  points  in  the 
same  plane  as  the  conjugate  and 
oblique  diameters ;  and  at  the 
outlet  from  the  centre  of  the  inner 
border  of  one  ischial  tuberosity  to 
that  of  the  other.  The  measure- 
ments  given  by  various  writers 


ANATOMY    OF    THE    PELVIS.  35 

differ  considerably,  and  vary  somewhat  in  different  pelves.  Taking 
the  average  of  a  large  number,  the  following  may  be  given  as  the 
standard  measurements  of  the  female  pelvis : — 

Anieio-po'^terior.  Oblique.  TranHvcrse. 

in.  iu.  ill. 

Brim 4.25  4.8  5.2 

Cavity 4.7  5.2  4.75 

Outlet 5.0  —  4.2 

It  will  be  observed  that  the  lengths  of  the  corresponding  dia- 
meters at  different  places  vary  greatly;  thus  while  the  transverse 
is  longest  at  the  brim,  the  oblique  is  longest  in  the  cavity,  and  the 
autero-posterior  at  the  outlet.  It  will  be  subsequently  seen  that 
this  fact  is  of  great  practical  importance  in  studying  the  mecha- 
nism of  delivery,  for  the  head  in  its  descent  through  the  pelvis  alters 
its  position  in  such  a  way  as  to  adapt  itself  to  the  largest  diameter 
of  the  pelvis;  thus  as  it  passes  through  the  cavity  it  lies  in  the 
oblique  diameter,  and  then  rotates  so  as  to  be  expelled  in  the  antero- 
posterior diameter  of  the  outlet. 

Diameters  as  altered  by  Soft  Parts. — In  thinking  of  these  measure- 
ments of  the  pelvis,  it  must  not  be  forgotten  that  they  are  taken  in 
the  dried  bones,  and  that  they  are  considerably  modified  during  life 
by  the  soft  parts.  This  is  especially  the  case  at  the  brim,  where  the 
projection  of  the  psoas  and  iliacus  muscles  lessens  the  transverse 
diameter  about  half  an  inch,  while  the  antero-posterior  diameter  of 
the  brim,  and  all  the  diameters  of  the  cavity,  are  lessened  by  a 
quarter  of  an  inch.  The  right  oblique  diameter  of  the  brim  is,  even 
in  the  dried  pelvis,  found  to  be,  on  an  average,  slightly  longer  than 
the  left ;  probably  on  account  of  the  increased  development  of  the 
right  side  of  the  pelvis  from  the  greater  use  made  of  the  right  leg; 
but  in  addition  to  this,  the  left  oblique  diameter  is  somewhat  lessened 
during  life  by  the  presence  of  the  rectum  on  the  left  side.  The 
advantage  gained  by  the  comparatively  frequent  passage  of  the  head 
through  the  pelvis  in  the  right  oblique  diameter  is  thus  explained. 

Other  Measurements. — There  are  one  or  two  other  measurements 
of  the  true  pelvis  which  are  sometimes  given,  but  which  are  of  sec- 
ondary importance.  One  of  these,  the  sacro-cotyloid  diameter,  is  that 
between  the  promontory  of  the  sacrum  and  a  point  immediately 
above  the  cotyloid  cavity,  and  averages  from  3.4  to  3.5  inches.  An- 
other, called  by  Wood  the  lower  or  inclined  conjugate  diameter,  is 
that  between  the  centre  of  the  lower  margin  of  the  symphysis  pubis 
and  the  promontory  of  the  sacrum,  and  averages  half  an  inch  more 
than  the  antero-posterior  diameter  of  the  brim.  These  measurements 
are  chiefly  of  importance  in  relation  to  certain  pelvic  deformities. 

External  Measurements. — The  external  measurements  of  the  pelvis 
are  of  no  real  consequence  in  normal  parturition,  but  they  may  help 
us,  in  certain  cases,  to  estimate  the  existence  and  amount  of  deformi- 
ties. Those  which  are  generally  given  are :  Between  the  anterior- 
superior  iliac  spines,  10  inches ;  between  the  central  points  of  the 
crests  of  the  ilia,  10 J  inches;  between  the  spinous  process  of  the  last 
lumbar  vertebra  and  the  u]3per  part  of  the  symphysis  pubis  (external 
conjugate),  7  inches. 


16 


ORGANS    CONCERNED    IN    PARTURITION. 


Planes  of  the  Pelvis. — By  the  planes  of  the  pelvis  are  meant  imagi- 
nary levels  at  any  portion  of  its  circumference.  If  we  were  to  cut 
out  a  piece  of  cardboard  so  as  to  fit  the  pelvic  cavity,  and  place  it 
either  at  the  brim  or  elsewhere,  it  would  represent  the  pelvic  plane 
at  that  particular  part,  and  it  is  obvious  that  we  may  conceive 
as  many  planes  as  we  desire.  Observation  of  the  angle  which  the 
pelvic  planes  form  with  the  horizon  shows  the  great  obliquity  at 
which  the  pelvis  is  placed  in  regard  to  the  spinal  column.  Thus 
the  angle  A  B  I  (Fig.  9)  represents  the  inclination  to  the  horizon  of 


Planes  of  the  Pelvis  with.  Horizon. 
A  B.     Horizon.  c  D.    Vertical  line. 

A  B  I.     Angle  of  inclination  of  pelvis  to  horizon,  equal  to  60^. 
B  I  c.    Angle  of  inclination  of  pelvis  to  spinal  column,  equal  to  150°. 
c  I  J.     Angle  of  inclination  of  sacrum  to  spinal  column,  equal  to  130°. 
E  P.     Axis  of  pelvic  inlet.  l  M.     Mid  plane  in  the  middle  line. 

N.    Lowest  point  of  mid  plane  of  ischium. 


the  plane  of  the  pelvic  brim,  i  B,  and  is  estimated  to  be  about  60^, 
while  the  angle  which  the  same  plane  forms  with  the  vertebral 
column  is  about  150^.  The  plane  of  the  outlet  forms,  with  the 
coccyx  in  its  usual  position,  an  angle  with  the  horizon  of  about  11°, 
but  which  varies  greatly  Avith  the  movements  of  the  tip  of  coccyx, 
and  the  degree  to  which  it  is  pushed  back  during  parturition.  These 
figures  must  only  be  taken  as  giving  an  approximative  idea  of  the 
inclination  of  the  pelvis  to  the  spinal  column,  and  it  must  be  remem- 
bered that  the  degree  of  inclination  varies  considerably  in  the  same 
female  at  different  times,  in  accordance  with  the  position  of  the  body. 
During  pregnancy  especially,  the  obliquity  of  the  brim  is  lessened  by 


ANATOMY    OF    THE    PELVIS.  37 

the  patient  throwing  herself  backwards  in  order  to  support  more 
easily  the  weight  of  the  gravid  uterus.  The  height  of  the  promon- 
tory of  the  sacrum  above  the  upper  margin  of  the  symphysis  pubis 
is  on  an  average  about  3f  inches,  and  a  line  passing  horizontally 
backwards  from  the  latter  point  would  impinge  on  the  junction  of 
the  second  and  third  coccygeal  bones. 

Axes  of  the  Parturient  Canal. — By  the  axis  of  the  pelvis  is  meant 
an  imaginary  line  which  indicates  the  direction  which  the  foetus 
takes  during  its  expulsion.     The  axis  of  the  brim  (Fig.  10)  is  a  line 

Fig.  10. 


Axes  of  the  Pelvis. 
A.  Axis  of  a  hupevior  plane.  b.  Axis  of  mid  plane.  c.  Axis  of  inferior  plane. 

D.  Axis  of  canal.  e.  Horizon. 

drawn  perpendicular  to  its  plane,  which  would  extend  from  the  um- 
bilicus to  about  the  apex  of  the  coccyx ;  the  axis  of  the  outlet  of  the 
bony  pelvis  intersects  this,  and  extends  from  the  centre  of  the  pro- 
montory of  the  sacrum  to  midway  between  the  tuberosities  of  the 
ischia.  The  axis  of  the  entire  pelvic  canal  is  represented  by  the  sum 
of  the  axes  of  an  indefinite  number  of  planes  at  different  levels  of 
the  pelvic  cavity,  which  forms  an  irregular  parabolic  line,  as  repre- 
sented in  the  accompanying  diagram  (Fig.  10,  A  d). 

It  must  be  borne  in  mind,  however,  that  it  is  not  the  axis  of  the 
bony  pelvis  alone  that  is  of  importance  in  obstetrics.  We  must 
always,  in  considering  this  subject,  remember  that  the  general  axis 
of  the  parturient  canal  (Fig.  11)  also  includes  that  of  the  uterine 
cavity  above,  and  of  the  soft  parts  below.  These  are  variable  in 
direction  according  to  circumstances;  and  it  is  only  the  axis  of  that 
portion  of  the  parturient  canal  extending  between  the  plane  of  the 
pelvic  brim  and  a  plane  between  the  lower  edge  of  the  pubic  sym- 
physis and  the  base  of  the  coccyx  that  is  fixed.     The  axis  of  the 


88 


ORGANS    CONCERNED    IN    PARTURITION, 


lower  part  of  the  canal  will  vary  according  to  the  amount  of  disten- 
sion of  the  perineum  during  labor;  but  when  this  is  stretched  to 
its  utmost,  just  before  the  expulsion  of  the  head,  the  axis  of  the  plane 


Fig.  11. 


Representing  General  Axis  of  Parturient  Canal,  inclnding  tlie  Uterine  Cavity  and  Soft  Parts. 


Fig.  12. 


between  the  edge  of  the  distended  perineum  and  the  lower  border  of 
the  symphysis,  looks  nearly  directly  forwards.  The  axis  of  the  ute- 
rine cavity  generally  corresponds  with  that  of  the  pelvic  brim,  but 

it  may  be  much  altered  by  abnor- 
mal positions  of  the  uterus,  such  as 
anteversion  from  laxity  of  the  abdo- 
minal walls.  The  foetus,  under  such 
circumstances,  will  not  enter  the 
brim  in  its  proper  axis,  and  diffi- 
culties in  the  labor  arise.  A  knoAvl- 
edge  of  the  general  direction  of 
the  parturient  canal  is  of  great  im- 
portance in  practical  midwifery 
in  guiding  us  to  the  introduction 
of  the  hand  or  instruments  in  ob 
stetric  operations,  and  in  showing 
us  how  to  obviate  difficulties  aris- 
ing from  such  accidental  deviations 
of    the    uterus   as   have    been    just 

Side  View  of  Pelvis.  alludcd  tO. 


ANATOMY    OF    THE    PELVIS.  39 

Cavity  of  tJie  Pelvis. — The  arrangements  of  the  Ijoncs  in  tlie  interior 
of  the  pelvic  canal  (Fig.  12 j  are  important  in  relation  to  the  mechanism 
of  delivery.  A  line  passing  between  the  spine  of  the  ischium  and  the 
ilio-pectiueal  eminence  divides  the  inner  surface  of  ischial  bone  into 
two  smooth  plane  surfaces,  which  have  received  the  name  of  the  planes 
of  the  ischium.  Two  other  planes  are  formed  by  the  inner  surfaces  of 
the  pubic  bones  in  front  and  by  the  upper  portion  of  the  sacrum  be- 
hind, both  having  a  direction  downwards  and  backwards.  In  study- 
ing the  mechanism  of  delivery,  it  will  be  seen  that  many  obstetricians 
attribute  to  these  planes,  in  conjunction  with  the  spine  of  the  ischium, 
a  very  important  influence  in  effecting  rotation  of  the  foetal  head 
from  the  oblique  to  the  antero-posterior  diameter  of  the  pelvis. 

Beveloiyinent  of  the  Pelvis. — The  peculiarities  of  the  pelvis  during 
infancy  and  childhood  are  of  interest  as  leading  to  a  knowledge  of 
the  manner  in  which  the  form  observed  during  adult  life  is  impressed 
upon  it.     The  sacrum  in  the  pelvis  of  the  child  (Fig.  18)  is  less  de- 

FiG.  13. 


Pelvis  of  a  Child. 


veloped  transversely,  and  is  much  less  deeply  curved  than  in  the 
adult.  The  pubes  is  also  much  shorter  from  side  to  side,  and  the 
pubic  arch  is  an  acute  angle.  The  result  of  this  narrowness  of  both 
the  pubes  and  sacrum  is  that  the  transverse  diameter  of  the  pelvic 
brim  is  shorter  instead  of  longer  than  the  antero-posterior.  The  sides 
of  the  pelvis  have  a  tendency  to  parallelism,  as  well  as  the  antero- 
posterior walls ;  and  this  is  stated  by  Wood  to  be  a  peculiar  charac- 
teristic of  the  infantile  pelvis.  The  iliac  bones  are  not  spread  out  as 
in  adult  life,  so  that  the  centres  of  the  crests  of  the  ilium  are  not 
more  distant  from  each  other  than  the  anterior  superior  spines.  The 
cavity  of  the  true  pelvis  is  small,  the  tuberosities  of  the  ischia  are 
proportionately  nearer  to  each  other  than  they  afterwards  become ; 
the  pelvic  viscera  are  consequently  crowded  up  into  the  abdominal 
cavity,  which  is,  for  this  reason,  much  more  prominent  in  children 
than  in_ adults.  The  bones  are  soft  and  semi-cartilaginous  until  after 
the  period  of  puberty,  and  yield  readily  to  the  mechanical  influences 


40  ORGANS    CONCERNED    IN    PARTURITION. 

to  which  they  are  subjected  ;  and  the  three  divisions  of  the  innomi- 
nate bone  remain  separate  until  about  the  twentieth  year. 

As  the  child  grows  older  the  transverse  development  of  the  sacrum 
increases,  and  the  pelvis  begins  to  assume  more  and  more  of  the  adult 
shape.  The  mere  growth  of  the  bones,  however,  is  not  sufficient  to 
account  for  the  change  in  the  shape  of  the  pelvis,  and  it  has  been 
well  shown  by  Duncan  that  this  is  chiefly  produced  by  the  pressure 
to  which  the  bones  are  subjected  during  early  life.  The  iliac  bones 
are  acted  upon  by  two  principal  and  opposing  forces.  One.  is  the 
weight  of  the  body  above,  which  acts  vertically  upon  the  sacral  ex- 
tremity of  the  iliac  beam  through  the  strong  posterior  sacro-iliac 
ligaments,  and  tends  to  throw  the  lower  or  acetabular  ends  of  the 
sacro-cotyloid  beams  outwards.  This  outward  displacement,  how- 
ever, is  resisted,  partly  by  the  junction  between  the  two  acetabular 
ends  at  the  front  of  the  pelvis,  but  chiefly  by  the, opposing  force, 
which  is  the  upward  pressure  of  the  lower  extremities  through  the 
femurs.  The  result  of  these  counteracting  forces  is  that  the  still 
soft  bones  bend  near  their  junction  with  the  sacrum  ;  and  thus  the 
greater  transverse  development  of  the  pelvic  brim  characteristic  of 
adult  life  is  established.  In  treating  of  pelvic  deformities  it  will  be 
seen  that  the  same  forces  applied  to  diseased  and  softened  bones  ex- 
plain the  peculiarities  of  form  that  they  assume. 

Pelvis  in  Different  Paces. — The  researches  that  have  been  made  on 
the  differences  of  the  pelvis  in  different  races  prove  that  these  are 
not  so  great  as  might  have  been  expected.  Joulin  pointed  out  that 
in  all  human  pelves  the  transverse  diameter  was  larger  than  the 
antero-posterior,  while  the  reverse  was  the  case  in  all  the  lower 
animals,  even  in  the  highest  simise.  This  observation  has  been  more 
recently  confirmed  by  Von  Franque,Mvho  has  made  careful  measure- 
ments of  the  pelvis  in  various  races.  In  the  pelvis  of  the  gorilla 
the  oval  form  of  the  brim,  resulting  from  the  increased  length  of  the 
conjugate  diameter,  was  very  marked.  In  certain  races  there  is  so 
far  a  tendency  to  animality  of  type,  that  the  difference  between  the 
transverse  and  conjugate  diameters  is  much  less  than  in  European 
women,  but  is  not  sufficiently  marked  to  enable  us  to  refer  any  given 
JDclvis  to  a  particular  race.  Von  Franque  makes  the  general  obser- 
vation that  the  size  of  the  pelvis  increases  from  South  to  North,  but 
that  the  conjugate  diameter  increases  in  proportion  to  the  transverse 
in  southern  races. 

Soft  Parts  in  Connection  with  Pelvis. — In  closing  the  description  of 
the  pelvis,  the  attention  of  the  student  must  be  directed  to  the  mus- 
cular and  other  structures  which  cover  it.  It  has  already  been 
pointed  out  that  the  measurements  of  the  pelvic  diameters  are  con- 
siderably lessened  by  the  soft  parts,  which  also  influence  parturition 
in  other  ways.  Thus  attached  to  the  crests  of  the  ilia  are  strong 
muscles  which  not  only  support  the  enlarged  uterus  during  pregnancy, 
but  are  powerful  accessory  muscles  in  labor  :  in  the  pelvic  cavity  are 
the  obturator  and  pyriformis  muscles  lining  it  on  either  side  ;   the 

'  Scanzoni's  Beitrage,  1867. 


THE  FEMALE  GENERATIVE  ORGANS.  41 

pelvic  cellular  tissue  and  fascias ;  the  rectum  and  bladder;  tlic  vessels 
and  nerves,  pressure  on  which  often  gives  rise  to  cramps  and  pains 
during  pregnancy  and  labor  ;  while  below  the  outlet  of  the  pelvis  is 
closed,  and  its  axis  directed  forwards  by  the  numerous  muscles  form- 
ing the  floor  of  the  pelvis  and  perineum. 


CHAPTEE   II. 

THE  FEMALE  GENERATIVE  ORGANS. 

Division  according  to  Function. — The  reproductive  organs  in  the 
female  are  conveniently  divided,  according  to  their  function,  into  : 
1,  The  external  or  copulative  organs,  which  are  chiefly  concerned  in 
the  act  of  insemination,  and  are  only  of  secondary  importance  in  par- 
turition :  they  include  all  the  organs  situated  externally  which  form 
the  vulva ;  and  the  vagina,  which  is  placed  internally  and  forms  the 
canal  of  communication  between  the  uterus  and  the  vulva.  2,  The 
internal  or  formative  organs :  they  include  the  ovaries,  which  are 
the  most  important  of  all,  as  being  those  in  which  the  ovule  is  formed  ; 
the  Fallopian  tubes,  through  which  the  ovule  is  carried  to  the  uterus; 
and  the  uterus,  in  which  the  impregnated  ovule  is  lodged  and  de- 
veloped. 

1.  The  external  organs  consist  of: — • 

Mons  Veneris. — The  mons  veneris,  a  cushion  of  adipose  and  fibrous 
tissue  which  forms  a  rounded  projection  at  the  upper  part  of  the 
vulva.  It  is  in  relation  above  with  the  lower  part  of  the  hypogas- 
tric region,  from  which  it  is  often  separated  by  a  furrow,  and  below 
it  is  continuous  with  the  labia  majora  on  either  side.  It  lies  over 
the  symphysis  and  horizontal  rami  of  the  pubes.  After  puberty  it 
is  covered  with  hair.  On  its  integument  are  found  the  openings  of 
numerous  sweat  and  sebaceous  glands. 

Labia  il/q/ora.— The  labia  majora  form  two  symmetrical  sides  to 
the  longitudinal  aperture  of  the  vulva.  They  have  two  surfaces, 
one  external,  of  ordinary  integument,  covered  with  hair,  and  another 
internal,  of  smooth  mucous  membrane,  in  apposition  with  the  corre- 
sponding portion  of  the  opposite  labium,  and  separated  from  the  ex- 
ternal surface  by  a  free  convex  border.  They  are  thicker  in  front, 
where  they  run  into  the  mons  veneris,  and  thinner  behind,  where 
they  are  united,  in  front  of  the  perineum,  by  a  thin  fold  of  integu- 
ment called  the  fourchette,  which  is  almost  invariably  ruptured  in 
the  first  labor.  In  the  virgin  the  labia  are  closely  in  apposition,  and 
conceal  the  rest  of  the  generative  organs.  After  child-bearing  they 
become  more  or  less  separated  from  each  other,  and  in  the  aged  they 
waste,  and  the  internal  nymphse  protrude  through  them.    Both  their 


42  ORGANS    CONCERNED    IN    PARTURITION. 

cutaneous  and  mucous  surfaces  contain  a  large  number  of  sebaceous 
glands,  opening  either  directly  on  the  surface  or  into  the  hair  folli- 
cles. In  structure  the  labia  are  composed  of  connective  tissue,  con- 
taining a  varying  amount  of  fat,  and  parallel  with  their  external 
surface  are  placed  tolerably  close  plexuses  of  elastic  tissue,  inter- 
spersed with  regularly  arranged  smooth  muscular  fibres.  These  fibres 
are  described  by  Broca  as  forming  a  membranous  sac,  resembling 
the  dartos  of  the  scrotum,  to  which  the  labia  majora  are  analogous. 
Towards  its  upper  and  narrower  end  this  sac  is  continuous  with  the 
external  inguinal  ring,  and  in  it  terminate  some  of  the  fibres  of  the 
round  ligament.  The  analogy  with  the  scrotum  is  further  borne 
out  by  the  occasional  hernial  protrusion  of  the  ovary  into  the  labium, 
corresponding  to  the  normal  descent  of  the  testis  in  the  male. 

Labia  Minora. — ^The  labia  minora,  or  nymphte,  are  two  folds  of 
mucous  membrane,  commencing  below,  on  either  side,  about  the 
centre  of  the  internal  surface  of  the  labium  externum  ;  they  converge 
as  they  proceed  upwards,  bifurcating  as  they  approach  each  other. 
The  lower  branch  of  this  bifurcation  is  attached  to  the  clitoris,  while 
the  upper  and  larger  unites  with  its  fellow  of  the  opposite  side,  and 
forms  a  fold  round  the  clitoris,  known  as  its  prepuce.  The  nymphte 
are  usually  entirely  concealed  by  the  labia  majora,  but  after  child- 
bearing  and  in  old  age  they  project  somewhat  beyond  them ;  then 
they  lose  their  delicate  pink  color  and  soft  texture,  and  become 
brown,  dry,  and  like  skin  in  appearance.  This  is  especially  the  case 
in  some  of  the  negro  races,  in  whom  they  form  long  projecting  folds 
called  the  apron. 

The  surfaces  of  the  nymphre  are  covered  with  a  tesselated  epithe- 
lium, and  over  them  are  distributed  a  large  number  of  vascular 
papillte,  somewhat  enlarged  at  their  extremities,  and  sebaceous 
glands,  which  are  more  numerous  on  their  internal  surfaces.  The 
latter  secrete  an  odorous,  cheesy  matter,  which  lubricates  the  surface 
of  the  vulva,  and  prevents  its  folds  adhering  to  each  other.  The 
nymphse  are  composed  of  trabeculee  of  connective  tissue,  containing 
muscular  fibres. 

Clitoris. — -The  clitoris  is  a  small  erectile  tubercle  situated  about 
half  an  inch  below  the  anterior  commissure  of  the  labia  majora.  It 
is  the  analogue  of  the  penis  in  the  male,  and  is  similar  to  it  in  struc- 
ture, consisting  of  a  corpus  cavernosura,  the  two  halves  of  which  are 
separated  by  a  fibrous  septum.  The  crura  are  covered  by  the  ischio- 
cavernous muscles,  which  serve  the  same  purpose  as  in  the  male.  It 
has  also  a  suspensory  ligament.  The  corpora  cavernosa  are  composed 
of  a  vascular  plexus  with  numerous  transversing  muscular  fibres. 
The  arteries  are  derived  from  the  perineal  artery,  and  give  a  branch, 
the  cavernous,  to  each  half  of  the  organ  ;  there  is  also  a  dorsal  artery 
distributed  to  the  prepuce.  According  to  Gussenbauer  these  caver- 
nous arteries  pour  their  blood  directly  into  large  veins,  and  a  finer 
venous  plexus  near  the  surface  receives  arterial  blood  from  small 
arterial  branches.  By  these  arrangements  the  erection  of  the  organ 
which  takes  place  during  sexual  excitement  is  favored.  The  nervous 
supply  of  the  clitoris  is  large,  being  derived  from  the  internal  pudic 


TUB  FEMALE  GENERATIVE  ORGANS.  43 

nerve,  which  supplies  brandies  to  the  corpora  cavernosa,  and  termi- 
nates in  the  glands  and  prepuce,  where  Paccinian  corpuscles  and  ter- 
minal bulbs  are  to  be  found.  On  this  account  the  clitoris  has  been 
supposed  by  some  to  be  the  chief  seat  of  voluptuous  sensation  in  the 
female. 

Vestibule. — The  vestibule  is  a  triangular  space,  bounded  at  its  apex 
by  the  clitoris,  and  on  either  side  by  the  folds  of  the  nymphai.  It  is 
smooth,  and,  unlike  the  rest  of  the  vulva,  is  destitute  of  sebaceous 
glands,  although  there  are  several  groups  of  muciparous  glands  open- 
ing on  its  surface.  At  the  centre  of  the  base  of  the  triangle  which 
is  formed  by  the  upper  edge  of  the  opening  of  the  vagina,  is  a  promi- 
nence, distant  about  an  inch  from  the  clitoris,  on  which  is  the  orifice 
of  the  urethra.  This  prominence  cavji  be  readily  made  out  by  the 
finger,  and  the  depression  upon  it — leading  to  the  urethra — is  of  im- 
portance as  our  guide  in  passing  the  female  catheter.  This  little 
operation  ought  to  be  performed  without  exposing  the  patient,  and 
it  is  done  in  several  ways.  The  easiest  is  to  place  the  tip  of  the 
index  finger  of  the  left  hand  (the  patient  lying  on  her  back)  on  the 
apex  of  the  vestibule,  and  slip  it  gently  down  until  we  feel  the  bulb 
of  the  urethra,  and  the  dimple  of  its  orifice,  which  is  generally  readily 
found.  If  there  is  any  difficulty  in  finding  the  orifice,  it  is  well  to 
remember  that  it  is  placed  immediately  below  the  sharp  edge  of  the 
lower  border  of  the  symphysis  pubis,  which  will  guide  us  to  it.  The 
catheter  (and  a  male  elastic  catheter  is  always  the  best,  especiall}^ 
during  labor,  when  the  urethra  is  apt  to  be  stretched)  is  then  passed 
under  the  thigh  of  the  patient,  and  directed  to  the  orifice  of  the 
urethra  by  the  finger  of  the  left  hand,  which  is  placed  upon  it.  We 
must  be  careful  that  the  instrument  is  really  passed  into  the  urethra, 
and  not  into  the  vagina.  It  is  advisable  to  have  a  few  feet  of  elastic 
tubing  attached  to  the  end  of  the  catheter,  so  that  the  urine  can  be 
passed  into  a  vessel  under  the  bed  without  uncovering  the  patient. 
If  the  patient  be  on  her  side,  in  the  usual  obstetric  position,  the  ope- 
ration can  be  more  readily  performed  by  placing  the  tip  of  the  finger 
in  the  vagina  and  feeling  its  upper  edge.  The  orifice  of  the  urethra 
lies  immediately  above  this,  and  if  the  catheter  be  slipped  along  the 
palmar  surface  of  the  finger,  it  can  generally  be  inserted  without 
much  trouble.  If,  however,  as  is  often  the  case  during  labor,  the 
parts  are  much  swollen,  it  may  be  difficult  to  find  the  aperture,  and 
it  is  then  always  better  to  look  for  the  opening  than  to  hurt  the 
patient  by  long-continued  efforts  to  feel  it.  [In  this  country,  the 
instrument  is  almost  always  introduced  when  possible,  with  the 
woman  on  her  back. — -Ed.] 

Urethra. — The  urethra  is  a  canal  1\  inches  in  length,  and  it  is  in- 
timately connected  with  the  anterior  wall  of  the  vagina,  through 
which  it  may  be  felt.  It  it  composed  of  muscular  and  erectile  tissue, 
and  is  remarkable  for  its  extreme  dilatability,  a  property  which  is 
turned  to  practical  account  in  some  of  the  operations  for  stone  in  the 
female  bladder. 

Orifice  of  the  Vagina. — The  orifice  of  the  vagina  is  situated  imme- 
diately below  the  bulb  of  the  urethra.     In  virgins  it  is   a  circular 


44  ORGANS    CONCERNED    IN    PARTURITION. 

opening,  but  in  women  who  have  borne  children  or  practised  sexual 
intercourse,  it  is,  in  the  undistended  state,  a  vertical  fissure.  In 
virgins  it  is  generally  more  or  less  blocked  up  by  a  fold  of  mucous 
membrane,  containing  some  cellular  tissue  and  muscular  fibres,  with 
vessels  and  nerves,  which  is  known  as  the  hymen.  This  is  most  ■ 
often  crescentic  in  shape,  with  the  concavity  of  the  crescent  looking 
upwards ;  sometimes,  however,  it  is  circular  with  a  central  opening, 
or  cribriform  ;  or  it  may  even  be  entirely  imperforate,  and  this  gives 
rise  to  the  retention  of  the  menstrual  secretion.  These  varieties  of 
form  depend  on  the  peculiar  mode  of  development  of  the  fold  of 
vaginal  mucous  membrane  which  blocks  up  the  orifice  of  the  vagina 
in  the  foetus,  and  from  which  the  hymen  is  formed.  The  density  of 
the  membrane  also  varies  in  different  individuals.  Most  usually  it 
is  very  slight,  so  as  to  be  ruptured  in  the  first  sexual  approaches,  or 
even  by  some  accidental  circumstance,  such  as  stretching  the  limbs, 
so  that  its  absence  cannot  be  taken  as  evidence  of  want  of  chastity. 
A  knowledge  of  this  fact  is  of  considerable  importance  from  a  medi- 
co-legal point  of  view.  Sometimes  it  is  so  tough  as  to  prevent  inter- 
course altogether,  and  may  require  division  by  the  knife  or  scissors 
before  this  can  be  effected  ;  and  at  others  it  rather  unfolds  than  rup- 
tures, so  that  it  may  exist  even  after  impregnation  has  been  effected, 
and  it  has  been  met  with  intact  in  women  who  have  habitually  led 
unchaste  lives.  In  a  few  rare  .cases  it  has  even  formed  an  obstacle 
to  delivery,  and  has  required  incision  during  labor. 

Carunculee  Myrtiformes. — The  carunculse  myrtiformes  are  small 
fleshy  tubercles,  varying  from  two  to  five  in  number,  situated  round 
the  orifice  of  the  vagina,  and  which  are  generally  supposed  to  be  the 
remains  of  the  ruptured  hymen.  Schroeder,  however,  maintains  that 
they  are  only  formed  after  child-bearing  in  consequence  of  parts  of 
the  hymen  having  been  destroyed  by  the  injuries  received  during 
the  passage  of  the  child. 

Vulvo-vayinal  Glands. — Near  the  posterior  part  of  the  vaginal 
orifice,  and  below  the  superficial  perineal  fascia,  are  situated  two 
conglomerate  glands  which  are  the  analogues  of  Cowper's  glands  in  . 
the  male.  Bach  of  these  is  about  the  size  and  shape  of  an  almond, 
and  is  contained  in  a  cellular  fibrous  envelope.  Internally  they  are 
of  a  yellowish- white  color,  and  are  composed  of  a  number  of  lobules 
separated  from  each  other  by  prolongations  of  the  external  envelope. 
These  give  origin  to  separate  ducts  which  unite  into  a  common  canal, 
about  half  an  inch  in  length,  which  opens  in  front  of  the  attached 
edge  of  the  hymen  in  virgins,  and  in  married  women  at  the  base  of 
one  of  the  carunculee  myrtiformes.  According  to  Huguier,  the  size 
of  the  glands  varies  much  in  different  women,  and  they  appear  to 
have  some  connection  with  the  ovary,  as  he  has  always  found  the 
largest  gland  to  be  on  the  same  side  as  the  largest  ovary.  They 
secrete  a  glairj^,  tenacious  fluid,  which  is  ejected  in  jets  during  the 
sexual  orgasm,  probably  through  the  spasmodic  action  of  the  peri- 
neal muscles.  At  other  times  their  secretion  serves  the  purpose  of 
lubricating  the  vulva,  and  thus  preserves  the  sensibility  of  its  mucous 
membrane. 


THE  FEMALE  GENERATIVE  ORGANS, 


45 


Fossa  Navicularls. — Immediately  behind  the  hymen  in  the  unmar- 
ried, and  between  it  and  the  perineum,  is  a  small  dcpi-ession  called 
the  fossa  navicularis,  which  disappears  after  childbearing. 

Perineum. — Tiic  perineum  separates  the  orifice  of  the  vagina  from 
that  of  the  rectum.  It  is  about  1 J  inches  in  breadth,  and  is  of  great 
obstetric  interest,  not  only  as  supporting  the  internal  organs  from 
below,  but  because  of  its  action  in  labor.  It  is  largely  stretched  and 
distended  by  the  presenting  part  of  the  child;  and  if  unusually  tough 
and  unyielding,  may  retard  delivery,  or  it  may  be  torn  to  a  greater 
or  less  extent,  thus  giving  rise  to  various  subsequent  troubles. 

Vascular  /Supply  of  the  Vulva. — The  structures  described  above 
together  form  the  vulva,  and  they  are  remarkable  for  their  abundant 
vascular  and  nervous  supply.  The  former  constitutes  an  erectile 
tissue  similar  to  that  which  has  already  been  described  in  the  cli- 
toris, and  which  is  especially  marked  about  the  bulb  of  the  vestibule 
(Pig.  14).     From  this  point,   and  extending  on  either  side  of  the 

Fig.  14. 


Vascular  Supply  of  Vulva.     (After  Kobelt.) 
(T,  Bulb  of  vestibule.     6.  Muscular  tissue  of  vagina,     c,  d,  e,/.  The  clitoris  aud  its  muscles,     ff,  h, 
i,  k,  I,  m,  n.  Veins  of  the  nymphse  and  clitoris  comiuunicating  with  the  epigastric  aud  obturator  veins. 


vagina,  there  is  a  well-marked  plexus  of  convoluted  veins,  which,  in 
their  distended  state,  are  likened  by  Dr.  Arthur  Farre  to  a  filled 
leech.  The  erection  of  the  erectile  tissue,  as  well  as  that  of  the  clitoris, 
is  brought  about  under  excitement,  as  in  the  male,  by  the  compression 
of  the  efferent  veins  by  the  contraction  of  the  ischio-cavernous  mus- 
cles, and  by  that  of  a  thin  layer  of  muscular  tissues  surrounding  the 
orifice  of  the  vagina,  and  described  as  the  constrictor  vaginae. 


46 


ORGANS    CONCERNED    IN    PARTURITION, 


Vagina. — The  vagina  is  the  canal  wliicli  forms  the  communication 
between  the  external  and  internal  generative  organs,  through  which 
the  semen  passes  to  reach  the  uterus,  the  menses  flow,  and  the  foetus 
is  expelled.  Koughly  speaking,  it  lies  in  the  axis  of  the  pelvis,  but 
its  opening  is  placed  anterior  to  the  axis  of  the  pelvic  outlet,  so  that 
its  lower  portion  is  carved  forwards.  It  is  narrow  below,  but  dilated 
above,  where  the  cervix  uteri  is  inserted  into  it,  so  that  it  is  more  or 
less  conoidal  in  shape.  Generally  speaking,  its  anterior  and  posterior 
walls  lie  closely  in  contact,  but  they  are  capable  of  very  wide  dis- 
tension, as  during  the  passage  of  the  foetus.  The  anterior  wall  of 
the  vagina  is  shorter  than  the  posterior,  the  former  measuring  on  an 
average  2|-  inches,  the  latter  3  inches ;  but  the  length  of  the  canal 
varies  greatly  in  dilYerent  subjects  and  under  certain  circumstances. 
In  front  the  vagina  is  closely  connected  Avith  the  base  of  the  bladder, 
so  that  when  tlie  vagina  is  prolapsed,  as  often  occurs,  it  drags  the 
bladder  with  it  (Fig.  15) ;  behind,  it  is  in  relation  with  the  rectum, 

Fig.  15. 


Longitudinal  Section  of  Body,  showing  Relations  of  Generative  Organs. 

but  less  intimately ;  laterally  with  the  broad  ligaments  and  pelvic 
fascia  ;  and  superiorly  with  the  lower  portion  of  the  uterus  and  folds 
of  peritoneum  both  before  and  behind.  The  vagina  is  composed  of 
mucous,  muscular,  and  cellular  coats.  The  mucous  lining  is  thrown 
into  numerous  folds.  These  start  from  longitudinal  ridges  which 
exist  on  both  the  anterior  and  posterior  walls,  but  most  distinctly  on 
the  anterior.     They  are  very  numerous  in  the  young  and  unmarried, 


THE  FEMALE  GENERATIVE  ORGANS.  47 

and  greatly  increase  the  sensitive  surface  of  the  vagina.  After  child- 
bearing,  and  in  the  aged,  they  become  atrophied,  but  they  never 
completely  disap{)ear,  and  towards  the  orifice  of  the  vagina,  where 
they  exist  in  greatest  abundance,  they  are  always  to  be  met  with. 
The  whole  of  the  mucous  membrane  is  lined  with  tcsselated  epithe- 
lium, and  it  is  covered  with  a  large  number  of  papilla?  either  conical 
or  divided,  which  are  higlily  vascular  and  project  into  the  epithelial 
layer.  Unlike  the  vulvar  mucous  membrane,  that  of  the  vagina 
seems  to  be  destitute  of  glands.  Beneath  the  epithelial  layer  is  a 
submucous  tissue  containing  a  large  number  of  clastic  and  some 
muscular  fibres,  derived  from  the  muscular  walls  of  the  vagina.  These 
are  strong  and  well-developed,  especially  toward  the  ostium  vaginje. 
They  consist  of  two  layers — an  internal  longitudinal,  and  an  external 
circular — with  oblique  decussating  fibres  connecting  the  two.  Below 
they  are  attached  to  the  iscbio-pubic  rami,  and  above  thev  are  con- 
tinuous with  the  muscular  coat  of  the  uterus.  The  muscular  tissue 
of  the  vagina  increases  in  thickness  during  pregnancy,  but  to  a  much 
less  degree  than  that  of  the  uterus.  Its  vascular  arrangements,  like 
those  of  the  vulva,  are  such  as  to  constitute  an  erectile  tissue.  The 
arteries  form  an  intricate  network  around  the  tube,  and  eventually 
end  in  a  submucous  capillary  plexus,  from  which  twigs  pass  to  supply 
the  papillas;  these  again  give  origin  to  venous  radicles  which  unite 
into  meshes  freely  interlacing  with  each  other,  and  forming  a  well- 
marked  venous  plexus. 

2.  Internal  Orjans  of  Generation. — The  internal  organs  of  gene- 
Tation  consist  of  the  uterus,  the  Fallopian  tubes,  and  the  ovaries ; 
and  in  connection  with  them  we  have  to  study  the  various  ligaments 
and  folds  of  peritoneum  which  serve  to  maintain  the  organs  in  posi- 
tion, along  with  certain  accessory  structures.  Phj'siologically,  the 
most  important  of  all  the  generative  organs  are  the  ovaries,  in  which 
the  ovules  are  formed,  and  which  dominate  the  entire  reproductive 
life  of  the  female.  The  Fallopian  tubes  which  convey  the  ovule  to 
the  uterus,  and  the  uterus  itself — whose  main  function  is  to  receive, 
nourish  and  eventually  expel  the  impregnated  product  of  the  ovary — 
may  be  said  to  be,  in  fact,  accessory  to  these  viscera.  Practicalljr, 
however,  as  obstetricians,  we  are  chiefly  concerned  with  the  uterus, 
and  may  conveniently  commence  with  its  description. 

Uterus.— The  uterus  is  correctly  described  as  a  pyriform  organ, 
flattened  from  before  backwards,  consisting  of  the  body,  with  its 
rounded  fundus,  and  the  cervix  which  projects  into  the  upper  part 
of  the  vaginal  canal.  In  the  adult  female  it  is  deeply  situated  in 
the  pelvis,  being  placed  between  the  bladder  in  front  and  the  rectum 
behind,  its  fundus  being  below  the  plane  of  the  pelvic  brim  (Fig.  16). 
It  only  assumes  this  position,  however,  towards  the  period  of  puberty ; 
and  in  the  foetus  it  is  placed  much  higher,  and  lies,  indeed,  entirely 
within  the  cavity  of  the  abdomen.  It  is  maintained  in  this  position 
partly  by  being  slung  by  its  ligaments,  which  we  shall  subsequently 
study,  and  partly  by  being  supported  from  below  by  the  pelvie  cel- 
lular tissue  and  the  fleshy  column  of  the  vagina.  The  result  is  that 
the  uterus,  in  the  healthy  female,  is  a  perfectly  movable  body,  alter- 


ORGANS    CONCERNED    IN    PARTURITION. 


ing  its  position  to  suit  the  condition  of  tlie  surrounding  viscera, 
especially  the  bladder  and  rectum,  which  are  subjected  to  variations 
of  size  according  to  their  fulness  or  emptiness.  When  from  anj 
cause — as,  for  example,  some  peri-uterine  inflammation  producing 
adhesions  to  the  surrounding  textures — the  mobility  of  the  organ  is 
interfered  with,  much  distress  ensues,  and  if  pregnancy  supervenes 
more  or  less  serious  consequences  may  result.  Generally  speaking, 
the  uterus  may  be  said  to  He  in  a  line  roughly  corresponding  with 
the  axis  of  the  pelvic  brim,  its  fundus  being  pointed  forwards  and 
its  cervix  lying  in  such  a  direction  that  a  line  drawn  from  it  would 
impinge  on  the  junction  between  the  sacrum  and  coccyx.    According 

Fig.  16. 


Transverse  Section  of  the  Body,  showing  Kelations  of  the  Fundus  Uteri. 
m.  Pubes.     a,  a  (in  front).    Eemainder  of  hypogastric  arteries,     a,  a  (behind).    Spermatic  vessels 
and  nerves.     B.  Bladder.     L,  L.  Eound  ligaments.     U.  Fundus  uteri,     t,  t.  Fallopian  tuhes.     o,  o. 
Ovaries,     r.  Kectuin.    g.  Eight  ureter,  resiing  ou  the  psoas  muscle,     c.  TJtero-sacral  ligaments,     v. 
Last  lumbar  vertebra. 

to  some  authorities,  the  uterus  in  early  life  is  more  curved  in  the 
anterior  direction,  and  is,  in  fact,  normally  in  a  state  of  ante-flexion. 
Sappey  holds  that  this  is  not  necessarily  the  case,  but  that  the  amount 
of  anterior  curvature  depends  on  the  emptiness  or  fulness  of  the 
bladder,  on  which  the  uterus,  as  it  were,  moulds  itself  in  the  unim- 
pregnated  state.  It  is  believed  also  that  the  body  of  the  uterus  is 
very  generally  twisted  somewhat  obliquely,  so  that  its  anterior  sur- 
face looks  a  little  towards  the  right  side,  this  probably  depending  on 
the  presence  and  frequent  distension  of  the  rectum  in  the  left  side  of 
the  pelvis.  The  anterior  surface  of  the  uterus  is  convex,  and  is 
covered  in  three-fourths  of  its  extent  by  the  peritoneum,  which  is 
intimately  adherent  to  it.  Below  the  reflection  of  that  membrane  it 
is  loosely  connected  by  cellular  tissue  to  the  bladder,  so  that  any 


THE  FEMALE  GENERATIVE  ORGANS, 


49 


downward  displacement  of  the  uterus  drags  tlie  bladder  along  with  it. 
The  posterior  surface  is  also  convex,  but  more  distinctly  so  than  the 
anterior,  as  may  be  observed  in  looking  at  a  transverse  section  of 
the  organ  (Fig.  17).     It  is  also  covered  by  peritoneum,  the  reflection 


Fig.  17. 


Transverse  Section  of  Uterus. 

of  which  on  the  rectum  forms  the  cavity  known  as  Douglas's  pouch. 
The  fundus  is  the  upper  extremity  of  the  uterus,  lying  above  the 
points  of  entry  of  the  Fallopian  tubes.  It  is  only  slightly  rounded 
in  the  virgin,  but  becomes  more  decidedly  and  permanently  rounded 
in  the  woman  who  has  borne  children. 

Dimensions. — -Until  the  period  of  puberty  the  uterus  remains  small 
and  undeveloped  (Fig.  18);  after  that  time  it  reaches  the  adult  size, 
at  which  it  remains  until  menstruation  ceases,  when  it  again  atrophies. 
If  the  woman  has  borne  children,  it  always  remains  larger  than  in 

Fig.  18. 


uterus  and  Appendages  in  an  Infant.      (After  Farre.) 

the  nullipara.  In  the  virgin  adult  the  uterus  measures  2|  inches 
from  the  orilice  to  the  fundus,  rather  more  than  half  being  taken  up 
by  the  cervix.  Its  greatest  breadth  is  opposite  the  insertion  of  the 
Fallopian  tubes ;  its  greatest  thickness,  about  11  or  12  lines,  oppo- 


50  ORGANS    CONCERNED    IN    PARTURITION. 

site  the  centre  of  its  body.  Its  average  weight  is  about  9  or  10 
drachms.  Independently  of  pregnancy,  the  uterus  is  subject  to  great 
alterations  of  size  towards  the  menstrual  period,  when  on  account  of 
the  congestion  then  present,  it  enlarges,  sometimes,  it  is  said,  con- 
siderably. This  fact  should  be  borne  in  mind,  as  this  periodical 
swelling  might  be  taken  for  an  early  pregnancy. 

Regional  Divisions. — For  the  purpose  of  description  the  uterus  is 
conveniently  divided  into  the  fundus^  with  its  rounded  upper  ex- 
tremity, situated  between  the  insertions  at  the  Fallopian  tubes ;  the 
hody^  which  is  bounded  above  by  the  insertion  of  the  Fallopian  tubes, 
and  below  by  the  upper  extremity  of  the  cervix,  and  which  is  the 
part  chiefly  concerned  in  the  reception  and  growth  of  the  ovum  ;  and 
the  cervix^  which  projects  into  the  vagina,  and  dilates  during  labor 
to  give  passage  to  the  child.  The  cervix  is  conical  in  shape,  measur- 
ing 11  to  12  lines  transverely  at  the  base,  and  6  or  7  in  the  antero- 
posterior direction  ;  while  at  the  apex  it  measures  7  to  8  transversely, 
and  5  antero-posteriorly.  It  projects  about  4  lines  into  the  canal  of 
the  vagina,  the  remainder  of  the  cervix  being  placed  above  the 
reflection  of  the  vaginal  mucous  membrane.  It  varies  much  in  form 
in  the  virgin  and  nulliparous  married  woman,  and  in  the  woman 
who  has  borne  children ;  and  the  differences  are  of  importance  in 
the  diagnosis  of  pregnancy  and  uterine  disease.  In  the  virgin  it  is 
regularly  pyramidal  in  shape.  At  its  lower  extremity  is  the  opening 
of  the  external  os  uteri,  forming  a  small  transverse  fissure,  sometimes 
difficult  to  feel,  and  generally  described  as  giving  a  sensation  to  the 
examining  finger  like  the  extremity  of  the  cartilage  at  the  tip  of  the 
nose.  It  is  bounded  by  two  lips,  the  anterior  of  which  is  apparently 
larger  on  account  of  the  position  of  the  uterus.  The  surface  of  the 
cervix,  and  the  borders  of  the  os,  are  very  smooth  and  regular. 

Changes  after  ChildUrih. —  In  women  who  have  borne  children 
these  parts  become  considerably  altered.  The  cervix  is  no  longer 
conical,  but  is  irregular  in  form  and  shortened.  The  lips  of  the  os 
uteri  become  fissured  and  lobulated,  on  account  of  partial  lacerations 
which  have  occurred  during  labor.  The  os  is  larger  and  more  irregu- 
lar in  outline,  and  is  sometimes  sufficiently  patulous  to  admit  the  tip 
of  the  finger.  In  old  age  the  cervix  atrophies,  and  after  the  change 
of  life  it  not  uncommonly  entirely  disappears,  so  that  the  orifice  of 
the  OS  uteri  is  on  a  level  with  the  roof  of  the  vagina. 

Internal  Surface  of  the  Uterus. — The  internal  surface  of  the  uterus 
comprises  the  cavities  of  the  body  and  cervix — -the  former  being 
rather  less  than  the  latter  in  length  in  virgins,  but  about  equal  in 
women  who  have  borne  children — separated  from  each  other  by 
a  constriction  forming  the  upper  boundary  of  the  cervical  canal. 
The  cavity  of  the  body  is  triangular  in  shape,  the  base  of  the  triangle 
being  formed  by  a  line  joining  the  openings  of  the  Fallopian  tubes, 
its  apex  by  the  upper  orifice  of  the  cervix  or  internal  os,  as  it  is 
sometimes  called.  In  the  virgin  its  boundaries  are  somewhat  convex, 
projecting  inwards.  After  childbearing  they  become  straight  or 
slightly  concave.     The  opposing  surfaces  or  the  cavity  are  always  in 


THE  FEMALE  GENERATIVE  ORGANS. 


51 


contact  in  tlie  healthy  state  or  arc  only  separated  from  each  other 
by  a  small  quantity  of  mucus. 

Cavity  of  the  Cervix. — The  cavity  of  the  cervix  is  spindle-shaped 
or  fusiform,  narrower  above  and  below,  at  the  internal  and  external 
OS  uteri,  and  somewhat  dilated  between  these  two  points.  It  is  flat- 
tened from  before  backwards,  and  its  opposing  surfaces  also  lie  in 
contact,  but  not  so  closely  as  those  of  the  body.  On  the  mucous 
lining  of  the  anterior  and  posterior  surfaces  is  a  prominent  perpen- 
dicular ridge,  with  a  lesser  one  at  each  side,  from  ivhich  transverse 
ridges  proceed  at  more  or  less  acute  angles.  Thsse  have  received 
the  name  of  the  arhor  vitse.  According  to  Guyon  the  perpendicular 
ridges  are  not  exactly  opposite,  so  that  they  tit  into  each  other,  and 
serve  more  completely  to  lill  up  the  cavity  of  the  cervix,  especially 
towards  the  internal  os  (Fig.  19).  The  arbor  vitas  is  most  distinct 
in  the  virgin,  and  atrophies  considerably  after  childbearing. 


Portiou  of  Interior  of  Cervix.      Enlarged  nine  diameters.      (After  Tyler  Smith,  and  Ilassall.) 


The  superior  extremity  of  the  cervical  canal  forms  a  narrow 
isthmus  separating  it  from  the  cavity  of  the  body,  and  measuring 
about  fthsof  an  inch  in  diameter.  Like  the  external  os,  it  contracts 
after  the  cessation  of  menstruation,  and  in  old  age  sometimes  becomes 
entirely  obliterated. 

Structure  of  the  Uterus. — The  uterus  is  composed  of  three  principal 
structures— the  peritoneal,  muscular,  and  mucous  coats.  The  peri- 
toneum forms  an  investment  to  the  greater  part  of  the  organ,  ex- 
tending downwards  in  front  to  the  level  of  the  os  internum,  and 
behind  to  the  top  of  the  vagina,  from  which  points  it  is  reflected 


52 


ORGANS    CONCERNED    IN    PARTURITION. 


upwards  on  the  bladder  and  rectum  respectively.  At  the  sides  the 
peritoneal  investment  is  not  so  extensive,  for  a  little  below  the  level 
of  the  Fallopian  tubes  the  peritoneal  folds  separate  from  each  other, 
forming  the  broad  ligaments  (to  be  afterwards  described) ;  here  it  is 
that  the  vessels  and  nerves  supplying  the  uterus  gain  access  to  it. 
At  the  upper  part  of  the  organ  the  ]'.)eritoneum  is  so  closely  adherent 
to  the  muscular  tissue  that  it  cannot  be  separated  from  it;  below  the 
connection  is  more  loose.     The  mass  of  the   uterine  tissue,  both  in 

the  body  and  cervix,  consists  of 
unstriped  muscular  fibres,  firmly 
united  together  by  nucleated  con- 
nective tissue  and  elastic  fibres. 
The  muscular  fibre  cells  are  large 
and  fusiform,  with  very  attenuated 
extremities,  generally  containing 
in  their  centre  a  distinct  nucleus. 
These  cells,  as  well  as  their  nuclei, 
become  greatly  enlarged  during 
pregnancy  (Fig.  21) ;  according  to 
Strieker,  this  is  only  the  case  with 
the  muscular  fibres  which  play  an 
important  part  in  the  expulsion  of  the  foetus,  those  of  the  outermost 
and  innermost  layers  not  sharing  in  the  increase  of  size.^  In  addi- 
tion to  these  developed  fibres  there  are,  especially  near  the  mucous 
coat,  a  number  of  round  elementary  corpuscles,  which  are  believed 


Muscular  Fibres  of  unimpregnated  Uterus. 
(After  Jarre.) 
a.  Pibres  united  by  connective  tissue.     6 
Separate  fibres  and  elementary  corpuscles. 


Fig.  21. 


Developed  Muscular  Fibres  from  tbo  Gravid  Uterus.    (After  Wagner.) 

by  Dr.  Farre^  to  be  the  elementary  form  of  the  muscular  fibres,  and 
Avhich  he  has  traced  in  various  intermediate  states  of  development. 
Dr.  John  Williams^  believes  that  a  great  part  of  the  muscular  tissue 
of  the  uterus,  rather  more  indeed  than  three-fourths  of  its  thickness, 
is  an  integral  part  of  the  mucous  membrane,  analogous  to  the  mus- 
cularis  mucosje  of  the  mucous  membrane  of  the  alimentary  canal. 
This  he  describes  as  being  separated  from  the  rest  of  the  muscular 
tissue  by  a  layer  of  rather  loose  connective  tissue,  containing  nume- 
rous vessels.     In  early  foetal  life,  and   in   the  uteri  of  some  of  the 


'  Comparative  Histology,  vol.  Hi.,  Syd.  See.  Trans.,  p.  477. 

2  The  Uterus  and  its  Appendages,  p.  632.. 

3  "On  the   Structure  of  the  Mucous  Membrane  of  the  Uterus,"  Obstet.  Journ., 
1875. 


THE  FEMALE  GENERATIVE  OROANS.  53 

loAver  animals,  this  appearance  is  very  distinct;  in  the  adult  female 
uterus,  however  it  cannot  be  readily  made  out. 

Arrangement  of  the  Muscular  Fibres. — On  examining  the  uterine 
tissue  in  an  unimpregnated  condition  no  definite  arrangement  of  its 
muscular  fibres  can  be  made  out,  and  the  whole  seem  blended  in  in- 
extricable confusion.  By  observation  of  their  relations  when  h}' per- 
trophied  dnring  pregnancy,  llelie^  has  shown  that  they  may,  speaking 
roughly,  be  divided  into  three  layers:  an  external;  a  middle,  chiefly 
longitudinal ;  and  an  internal,  chiefly  circular.  Into  the  details  of 
their  distribution,  as  described  by  him  it  is  needless  to  enter  at  length. 
Briefly,  however,  he  describes  the  external  layer  as  arising  posteriorly 
at  the  junction  of  the  body  and  cervix,  and  spreading  upwards  and 
over  the  fundus.  From  this  are  derived  the  muscular  fibres  found  in 
the  broad  and  round  ligaments,  and  more  particularly  described  by 
Eouget.  The  middle  layer  is  made  up  of  strong  fasciculi,  which  run 
upwards,  but  decussate  and  unite  with  each  other  in  a  remarkable 
manner,  so  that  those  which  are  at  first  superficial  become  most 
deeply  seated,  and  vice  versa.  The  muscular  fasciculi  Avhich  form 
this  coat  curve  in  a  circular  manner  around  the  large  veins,  so  as  to 
form  a  species  of  muscular  canal  through  which  they  run.  This 
arrangement  is  of  peculiar  importance,  as  it  affords  a  satisfactory  ex- 
planation of  the  mechanism  by  which  hemorrhage  after  delivery  is 
prevented.  The  internal  layer  is  mainly  composed  of  circular  rings 
of  muscular  fibres,  beginning  round  the  openings  of  the  Fallopian 
tubes,  and  forming  wider  and  wider  circles  which  eventually  touch 
and  interlace  with  each  other.  They  surround  the  internal  os,  to 
which  they  form  a  kind  of  sphincter.  In  addition  to  these  circular 
fibres  on  the  internal  uterine  surface,  both  anteriorly  and  posteriorly, 
there  is  a  well-marked  triangular  layer  of  longitudinal  fibres,  the 
base  being  above  and  the  apex  below,  which  sends  muscular  fasciculi 
into  the  mucous  membrane. 

Its  Mucous  Membrane. — -The  anatomy  of  the  lining  membrane  of 
the  uterus  has  been  the  subject  of  considerable  discussion.  Its  exist- 
ence has  been  denied  by  many  authorities,  most  recently  by  Snow 
Beck,^  who  maintains  that  it  is  in  no  sense  a  mucous  membrane,  but 
only  a  softened  portion  of  true  uterine  tissue.  It  is,  however,  pretty 
generally  admitted  by  the  best  authorities  that  it  is  essentially  a 
mucous  membrane,  differing  from  others  only  in  being  more  closely 
adherent  to  the  subjacent  structures,  in  consequence  of  not  possessing 
any  definite  connective  tissue  framework. 

It  is  a  pale  pink  membrane  of  considerable  thickness,  most  marked 
at  the  centre  of  the.  body,  where  it  forms  from  |-th  to  ^th  of  the 
thickness  of  the  whole  uterine  walls.  At  the  internal  os  uteri  it 
terminates  by  a  distinct  border,  which  separates  it  from  the  mucous 
membrane  lining  the  cervical  cavity. 

The  Utricular..  Glands. — On  the  surface  of  the  mucous  membrane 
may  be  observed  a  multitude  of  little  openings,  about  -^^th  of  a  line 

'  Recherchws  sur  la  disposition  des  Fibres  musculaires  de  I'Uterus.     Paris,  1869. 
2  Obst.  Trans.,  vol.  xiii.  p.  294. 


54 


ORGANS    CONCERNED    IN    PARTURITION, 


in  width  (Fig.  22).     These  are  the  orifices  of  the  utricular  glands, 
which  are  found  in  immense  numbers  all  over   the   cavity  of  the 


Fig.  22. 


Fig.  23. 


Lining  Membrane  ot  Uteius,  showing  network  of  Capillaries  and  Orifices  of  Uteriue  Glands. 

(After  Farre.) 

Trom  the  body.  From  orifice  of  Fallopian  tube. 

uterus,  and  very  closely  agglomerated  together.  They  are  little  culs- 
de-sac,  narrower  at  their  mouths  than  in  their  length,  the  blind  ex- 
tremities of  which  are  found  in  the  sub- 
jacent tissues.  Williams  describes  them 
as  running  obliquely  towards  the  surface 
at  the  lower  third  of  the  cavity,  perpen- 
dicularly at  its  middle,  while  towards  the 
fundus  they  are  at  first  perpendicular,  and 
then  oblique  in  their  course  (Fig.  23).  By 
others  they  are  described  as  being  often 
twisted  and  corkscrew -like.  One  or  more 
may  unite  to  form  a  common  orifice, 
several  of  which  may  open  together  in 
little  pits  or  depressions  on  the  surface  of 
the  mucous  membrane.  These  glands  are 
composed  of  structureless  membrane  lined 
with  epithelium,  the  precise  character  of 
which  is  doubtful.  By  some  it  is  described 
as  columnar,  by  others  tessellated,  and  by 
some  again  as  ciliated.  The  most  gener- 
ally received  opinion  is  that  it  is  columnar, 
but  not  ciliated;  therein  differing  from 
the  epithelium  covering  the  surface  of  the 
membrane,  which  is  undoubtedly  ciliated, 
the  movements  of  the  cilia  being  from 
within  outwards.  Williams,  however,  has 
observed  cilia  in  active  movement  on  the 
columnar  epithelium  lining  the  glands,  and 
also  states  that  at  the  deep-seated  extremi- 
The  conrse  of  the  Glands  in  the  tics  of  the  glauds,  which  penetrate  between 
fully  developed  Mucous  Mem-    the  muscular  fibrcs  for  sonic  distancc,  the 

columnar  epithelium  is  replaced  by  rounded 
cells.  The  capillaries  of  the  mucous  mem- 
brane run  down  between  the  tubes,  form- 
ing a  lacework  on  their  surfaces,  and  round  their  orifices.  No  true 
papillfe   exist   in   the   membrane    lining   the   uterine    cavity.      The 


brane  of  the  Uterns,  viz.,  just  be- 
fore the  onset  of  a  menstrual 
period.     (Al'ter  Williams^ 


THE  FEMALE  GENERATIVE  ORGANS. 


55 


mucous  membrane  of  the  uterus  is  peculiar  in  being  alwavs  in  a 
ptate  of  change  and  alteration,  being  thrown  oft'  at  each  menstrual 
period  in  the  form  of  debris,  in  consequence  of  fatty  degeneration 
of  its  structures,  and,  reformed  afresh  by  proliferation  of  the  cells  of 
the  muscular  and  connective  tissues,  probably  from  below  upwards, 
the  new  membrane  commencing  at  the  internal  os.  Hence  its 
appearance  and  structure  vary  considerably  according  to  the  time  at 
which  it  is  examined.  This  subject,  however,  will  be  more  j)articu- 
larly  studied  in  connection  with  menstruation. 

Mucous  Membrane  of  the  Cervix. — The  mucous  membrane  of  the 
cervix  is  much  thicker  and  more  transparent  than  that  of  the  body 
of  the  uterus,  from  which  it  also  differs  in  certain  structural  peculiari- 
ties. The  general  arrangements  of  its  folds  and  surface  have  already 
been  described.  The  lower  half  of  the  membrane  lining  the  cavity  of 
the  cervix,  and  the  whole  of  that  covering  its  external  or  vaginal  por- 
tion, are  closely  set  with  a  large  number  of  minute  filiform,  or  clavate 
papillae  (Fig.  24).     Their  structure  is  similar  to  that  of  the  mucous 

Fig.  24. 


Villi  of  Os  uteri  stripped  of  Epithelium.     (After  Tyler  Smith  and  Hassall.) 

membrane  itself,  of  which  they  seem  to  be  merely  elevations.  They 
eaph  contain  a  vascular  loop  (Fig.  25),  and  they  are  believed  by 
Kilian  and  Farre  to  be  mainly  concerned  in  giving  sensibility  to  this 
part  of  the  generative  tract.  All  over  the  interior  of  the"  cervix, 
both  on  the  ridges  of  the  mucous  membrane  and  between  their  folds, 
are  a  very  large  number  of  mucous  follicles,  consisting  of  a  structure- 
less membrane  lined  with  cylindrical  epithelium,  and  intimately 
united  with  the  connective  tissue.    They  cease  at  the  external  orifice 


56 


ORGANS    CONCERNED    IN    PARTURITION, 


of  tlie  cervix,  and  they  secrete  the  thick,  tenacious,  and  alkaline 
mucus  which  is  generally  found  filling  the  cervical  cavitv.  The 
transparent  follicles,  known  as  the  '' ovula  Nahothii,''  which  are  some- 
times found  in  considerable  numbers  in  the  cavity  of  the  cervix  con- 
sist of  mucous  follicles  the  mouths  of  which  have  become  obstructed 
and  their  canals  distended  by  mucous  secretion.  The  lower  third 
of  the  cervical  canal  as  well  as  the  exterior  of  the  cervix,  are  covered 
with  pavement  epithelium ;  ivhile  on  its  upper  portion  is  found  a 
columnar  and  ciliated  epithelium  similar  to  that  lining  the  uterine 
cavity. 

Fig.  25. 


^^-^■^ 


YiHi  of  uterus  covered  with  Pavement  Epithelium,  and  cont;iining  Looped  Vessels.     (After  Tyler 

Smith  and  Hassall.) 


Vessels  of  the  Uterus.- — The  arteries  of  the  uterus  are  derived  from 
the  internal  iliac,  and  from  the  ovarian.  They  enter  the  uterus  be 
tween  the  folds  of  the  broad  ligaments,  and,  penetrating  its  muscular 
coat,  anastomose  freely  with  each  other  and  with  the  corresponding 
vessels  of  the  opposite  side.  Their  walls  are  thick  and  well-devel- 
oped, and  they  are  remarkable  for  their  very  tortuous  course,  forming 
spiral  curves,  especially  in  the  upper  part  of  the  uterus.  They  end 
in  minute  capillaries  which  form  the  fine  meshes'  surrounding  the 
glands,  and  in  the  cervix,  give  off  the  loops  entering  the  papillaa. 
Beneath  the  uterine  mucous  membrane  these  capillaries  form  a  plexus, 
terminating  in  veins  without  valves,  which  unite  with  each  other  to 
form  the  large  veins  traversing  the  substance  of  the  uterus,  known 
during  pregnancy  as  the  uterine  sinuses,  the  walls  of  which  are  closely 
adherent  to  the  uterine  tissues.  These  veins,  freely  anastomosing 
with  each  other,  pass  outwards  to  the  folds  of  the  broad  ligaments, 


THE  FEMALE  GENERATIVE  ORGANS.  57 

where  they  unite  to  form,  with  the  ovarian  and  vaginal  veins,  a  large 
and  well -developed  venous  network,  known  as  the  pampiniforra 
plexus. 

Lymphatics  of  the  Uterus.- — The  lymphatics  of  the  uterus  are  large 
and  well  developed,  and  they  have  rccentlj''.  and  with  much  proba- 
bility, been  supposed  to  play  an  important  part  in  the  production  of 
certain  puerperal  diseases,  A  more  minute  knowledge  than  we  at 
present  possess  of  their  course  and  distribution  will  probably  throw 
much  light  on  their  influence  in  this  respect.  According  to  the  re- 
searches of  Leopold,^  who  has  studied  their  minute  anatomy  care- 
fully, they  originate  in  lymph  spaces  between  the  fine  bundles  of 
connective  tissue  forming  the  basis  of  the  mucous  lining  of  tlie  uterus. 
Here  they  are  in  intimate  contact  Avith  the  utricular  glands  and  the 
ultimate  ramifications  of  the  uterine  bloodvessels.  As  they  pass 
into  the  muscular  tissue  they  become  gradually  narrowed  into  lymph- 
vessels  and  spaces,  wliich  have  a  very  complicated  arrangement,  and 
which  eventually  unite  together  in  the  external  muscular  layer,  espe- 
cially on  the  sides  of  the  uterus,  to  form  large  canals  which  probably 
have  valves.  Immediately  under  the  peritoneal  covering  these 
lymph-vessels  form  a  large  and  characteristic  network  covering  the 
anterior  and  posterior  surfaces  of  the  uterus,  and  present,  in  various 
jiarts  of  their  course,  large  ampuUte.  They  then  spread  over  the 
Fallopian  tubes.  The  lymphatics  of  the  body  of  the  uterus  unite 
with  the  lumbar  glands,  those  of  the  ceivix  with  the  pelvic  glands. 

Nerves  of  the  Uterus. — The  distribution  and  arrangement  of  the 
nerves  of  the  uterus  have  been  the  subject  of  much  controversy. 
They  are  derived  mainly  from  the  ovarian  and  hypogastric  plexuses, 
ino^culatiing  freely  with  each  other  between  the  folds  of  the  broad  liga- 
ment, from  which  they  enter  the  muscular  tissue  of  the  uterus  gene- 
rally, but  not  invariably,  following  the  course  of  the  arteries.  They 
are  chiefly  derived  from  the  sympathetic ;  but,  as  the  hypogastric 
plexus  is  connected  with  the  sacral  nerves,  it  is  probable  that  some 
fibres  from  the  cerebro-spinal  system  are  distributed  to  the  cervix. 
It  is  now  generally  admitted  that  nervous  filaments  are  distributed 
to  the  cervix,  even  as  far  as  the  external  os  although  their  existence 
in  this  situation  has  been  denied  by  Jobert  and  other  writers.  The 
ultimate  distribution  of  the  nerves  is  not  yet  made  out.  Polle  de- 
scribes a  nerve  filament  as  entering  the  papillge  of  the  cervical  mu- 
cous membrane  along  with  the  capillary  loop,  and  Frankenhauser 
says  the  nerve  fibres  surround  the  muscles  of  the  uterus  in  the  form 
of  plexuses  and  terminate  in  the  nuclei  of  the  muscle  cells. 

Anomalies  of  the  Uterus. — Yarious  abnormal  conditions  of  the 
uterus  and  vagina  are  occasionally  met  with,  which  it  is  necessary 
to  mention,  as  they  may  have  an  important  practical  bearing  on 
parturition.  The  most  frequent  of  these  is  the  existence  of  a  double, 
or  partially  double,  uterus  (Fig.  26),  similar  to  that  found  normally 
in  many  of  the  lower  animals.  Tliis  abnormalitv  is  explained  by  the 
development  of  the  organ  during  foetal  life.     The  uterus  is  formed 

'  Arch.  f.  Gynak.  Bd.  vi.  Heft  i. 


t)8  ORGANS    CONCERNED    IN    PARTURITION. 

out  of  structures  existing  only  in  early  foetal  life,  known  as  the 
Wollian  bodies.  These  consist  of  a  number  of  tubes,  situated  on 
either  side  of  the  vertebral  column,  and  opening  internally  into  an 
excretory  duct.  Along  their  external  border  a  hollow  canal  is 
formed,  termed  the  canal  of  Miiller,  which  like  the  excretory  ducts, 
proceeds  to  the  common  cloaca  of  the  digestive  and  urinary  organs 
which  then  exists.  The  canal  of  Miiller  unites  with  its  fellow  of  the 
opposite  side  to  form  the  uterus  and  Fallopian  tubes  in  the  female, 
and  subsequently  the  central  partition  at  their  point  of  junction  dis- 
appears. If,  however,  the  progress  of  development  be  in  any  way 
checked,  the  central  partition  may  remain.    Then  we  have  produced 

Fig.  26. 


Bifid  Uterus.     (After  Farre.) 

either  a  complete  double  uterus  or  the  uterus  bicornis,  which  is  bifid 
at  its  upper  extremity  only ;  or  a  double  vagina,  each  leading  to 
a  separate  uterus. 

Precjnayicy  in  cases  of  Bifid  Uterus. — If  pregnancy  occur  in  any  of 
these  anomalous  uteri,  and  many  such  cases  are  recorded,  serious 
troubles  may  follow.  It  may  happen  that  one  horn  of  a  double 
uterus  is  not  sufficiently  large  to  admit  of  pregnancy  going  on  to 
term,  and  rupture  may  occur.  It  is  supposed  that  some  cases,  pre- 
sumed to  be  tubal  gestation,  were  really  thus  explicable.  Impreg- 
nation may  also  occur  in  the  two  cornua  at  different  times,  leading 
to  superfoetation.  It  is,  however,  quite  possible  that  impregnation 
may  occur  in  one  horn  of  a  bifid  uterus,  and  labor  be  completed  with- 
out anything  unusual  being  observed.  A  remarkable  case  of  this 
sort  has  been  recorded  by  Dr.  Ross  of  Brighton,^  in  wdiich  a  patient 
miscarried  of  twins  on  July  16, 1870,  and  on  October  31,  fifteen  weeks 
later,  she  was  delivered  of  a  healthy  child.  Careful  examination 
showed  the  existence  of  a  complete  double  uterus,  each  side  of  which 
had  been  impregnated.  Curiously  enough,  this  patient  had  formerly 
given  birth  to  six  living  children  at  term,  nothing  remarkable  having 
been  observed  in  her  labors.  It  can  onl_y  rarely  happen,  that,  under 
such  circumstances,  so  favorable  a  result  will  follow,  and  more  or 
less  difficulty  and  danger  may  generally  be  expected.     Occasionally 

1  Lancet,  August,  1871. 


THE  FEMALE  GENERATIVE  ORGANS. 


59 


the  vagina  only  is  double,  the  uterus  being  single.  Dr.  ]\[atthews 
Duncan  has  recorded  some  cases  of  this  kind/  in  which  the  vaginal 
septum  formed  an  obstacle  to  the  birth  of  the  child,  and  required 
division. 

[As  there  have  been  reported  in  the  United  States,  within  a  short 
period,  no  less  than  five  cases  of  pregnancy,  four  of  them  within  two 
years,  in  which  it  has  been  claimed  that  a  tubal  foetal  cyst  discharged 
its  contents  into  the  uterine  cavity,  and  from  this  through  the  vagina, 
I  have  thought  it  well  to  introduce  here,  the  illustration  of  Kuss- 
maul,  which  is  in  itself  a  proof,  that  the  uterus  although  to  the  sense 
of  touch  and  external  manipulation  of  normal  form,  may  be  in  fact 
as  decidedly  duplex  as  a  bifid  organ. 


Partitioned  Uterus. 


_  A  much  less  rare  form  than  this,  is  the  half  developed  uterus,  one 
side  being  in  a  rudimentary  state.  Such  an  organ  may  become  im- 
pregnated in  its  rudimentary  cornu,  which  will  either  burst  as  it 
develops,  or,  what  more  rarely  happens,  discharge  its  contents  per 
vaginam.  To  distinguish  such  a  form  of  pregnancy,  from  the  Fallo- 
pian variety  at  the  proximal  end  of  the  tube,  has  been  generally 
claimed  as  impossible  during  life,  and  difficult  even  after  death,  cer- 
tain anatomical  points  being  required  in  proof. 

Although  we  have  high  American  authorities  in  New  York  and 
Philadelphia  who  claim  to  have  diagnosed  true  tubal  pregnancies  in 


Researches  in  Obstetrics,  p.  443. 


60  ORGANS    CONCETINED    IN    PARTURITION. 

the  cases  referred  to,  we  know  that  the  most  celebrated  gynaecolo- 
gists have  been  at  times  mistaken,  and  that  their  errors  have  been 
revealed  under  the  knife  of  the  surgeon,  or  anatomist. 

^Two  of  the  reports  are  illustrated  by  drawings,  representing  a 
normal  uterus  and  a  dilated  Fallopian  tube,  just  such  as  we  should 
expect  to  burst  eventually  into  the  abdominal  cavity.  I  should 
like  to  believe  a  per  vayinam  delivery  possible  in  such  a  case, 
and  should  be  glad  to  have  a  post-mortem  proof  to  this  effect : 
but  certainly  our  studies  of  tubal  and  interstitial  specimens  have 
not  prepared  the  medical  profession  to  anticipate  so  fortunate  a 
termination.  When  the  uterus  is  perfectly  normal,  the  Fallopian 
cyst  if  close  to  it  is  found  to  be  developed  in  the  least  resisting 
direction,  which  is  of  course  toward  the  distal  extremity  of  the 
tube.  If  then  the  tubal  sac  contracts  as  has  been  claimed,  with 
pains  like-  those  of  labor,  we  should  not  expect  it  to  exert  an 
amount  of  muscular  force  sufficient  to  overcome  the  resistance  at 
the  utero-tubal  orifice,  but  to  empty  its  contents  if  at  all,  through  a 
rent  at  its  weakest  part. 

If  it  be  possible  that  an  ovum  can  develop  itself  in  the  proximal 
end  of  the  Fallopian  tube,  without  as  it  usually  does,  penetrating  its 
wall  and  becoming  interstitial,  then  such  a  delivery  might  be  possible, 
provided  the  wall  of  the  cyst  next  to  the  uterine  cavity,  shall  not  as 
is  quite  common  in  the  true  interstitial  variety,  become  its  thickest 
portion.  I  can  easily  form  in  theory  just  such  a  cyst,  as  would  of 
necessity  empty  itself  into  the  uterine  cavity  ;  but  would  it  be  true  to 
nature  in  any  case?  Having  now  five  of  these  remarkable  subjects 
in  our  two  largest  cities,  it  is  to  be  hoped  for  the  good  of  science,  and 
the  settlement  of  a  doubtful  question,  that  at  some  future  day  their 
pelvic  organs  may  be  examined  after  death. — Ed.] 

Ligaments  of  the  Uterus.— ^\\q  various  folds  of  peritoneum  which 
invest  the  uterus  serve  to  maintain  it  in  position,  and  they  are  de- 
scribed as  its  ligaments.  They  are  the  broad,  the  vesico-uterine,  and 
sacro-uterine  ligaments  ;  the  round  ligaments  are  not  peritoneal  folds 
like  the  others. 

Broad  Ligaments. — The  broad  ligaments  extend  from  either  side 
of  the  uterus,  where  their  laminas  are  separated  from  each  other, 
transversely  across  to  the  pelvic  wall,  and  thus  divide  the  cavity  of 
the  pelvis  into  two  parts ;  the  anterior  containing  the  bladder,  the 
posterior  the  rectum.  Their  upper  borders  are  divided  into  three 
subsidiary  folds,  the  anterior  of  Avhich  contams  the  round  ligament, 
the  middle  the  Fallopian  tube,  and  the  posterior  the  ovary.  This 
arrangement  has  received  the  name  of  the  aJa  vespertiUo7iis,  from  its 
fancied  resemblance  to  a  bat's  wing.  Between  the  folds  of  the  broad 
ligaments  are  found  the  uterine  vessels  and  nerves,  and  a  certain 
amount  of  loose  cellular  tissue  continuous  with  the  pelvic  fasciae. 
Here  is  situated  that  peculiar  structure  called  the  organ  of  Rosen- 
miilier,  or  the  parovarium  (Fig.  28),  which  is  the  remains  of  the 
Wolffian  body,  and  corresponds  to  the  epididymis  in  the  male.    This 

[1  N.  Y.  Med.  Jour.  vol.  xxvii.  p.  273  ;  vol.  xxviii.  1878,  p.  595.] 


THE  FEMALE  GENERATIVE  ORGANS.  61 

may  best  be  seen  in  young  subjects,  by  liolding  up  the  broad  liga- 
ments and  looking  through  them  by  transmitted  light ;  but  it  exists 
at  all  ages.  It  consists  of.  several  tubes  (eight  or  ten  according  to 
Farre,  eighteen  or  twenty  according  to  Bankes'),  which  are  tortuous 

Fig.  28. 


Adult  Parovarium,  Ovary,  and  FaUopian  Tube.     (After  Kobelt.) 

in  their  course.  They  are  arranged  in  a  pyramidal  form,  the  base 
of  the  pyramid  being  towards  the  Fallopian  tube,  its  apex  being  lost 
on  the  surface  of  the  ovary.  They  are  formed  of  fibrous  tissue,  and 
lined  with  pavement  epithelium.  They  have  no  excretory  duct,  or 
communication  with  either  the  uterus  or  ovary,  and  their  function, 
if  they  have  any,  is  unknown. 

Muscular  Fibres  between  its  Folds. — A  number  of  muscular  fibres 
are  also  found  in  this  situation,  lying  between  the  meshes  of  the 
connective  tissue.  They  have  been  particularly  studied  by  Eouget, 
who  describes  them  as  interlacing  with,  each  other,  and.  forming  an 
open  network,  continuous  with  the  muscular  tissue  of  the  uterus 
(Fig.  29).  They  are  divisible  into  two  layers,  the  anterior  of  which 
is  continuous  with  the  muscular  fibres  of  the  anterior  surface  of  the 
uterus,  and  goes  to  form  part  of  the  round  ligament ;  the  posterior 
arises  from  the  posterior  wall  of  the  uterus,  and  proceeds  transversely 
outwards,  to  become  attached  to  the  sacro-iliac  syn<}hondrosis.  A 
continuous  muscular  envelope  is  tlius  formed,  Avhich  surrounds  the 
whole  of  the  uterus.  Fallopian  tubes,  and  ovaries.  Its  function  is 
not  yet  thoroughly  established.  It  is  supposed  to  have  the  effect  of 
retracting  the  stretched  folds  of  peritoneum  after  delivery,  and  more 
especially  of  bringing  the  entire  generative  organs  into  harmonious 
action  during  menstruation  and  the  sexual  orgasm ;  in  this  way 
explaining,  as  we  shall  subsequently  see,  the  mechanism  by  which 
the  fimbriated  extremity  of  the  Fallopian  tube  grasps  the  ovary  prior 
to  the  rupture  of  a  Graafian  follicle. 

Round  Ligaments. — The  round  ligaments  are  essentially  muscular 
in  structure.     They  extend  from  the  upp3r  border  of  the  uterus, 

I  Bankes,  On  the  Wolffian  Bodies. 


GZ 


ORGANS    CONCERNED    IN    PARTURITION. 


with  the  fibres  of  which  their  muscular  fibres  are  continuous,  trans- 
versely and  then  obliquely  downwards,  until  they  reach  the  inguinal 


Fig.  29. 


Posterior  View  of  Muscular  and  Vascular  Arrangements.     (After  Eouget.) 

Vessels. — 1,  2,  3.  Vaginal,  cervical,  and  uterine  plexuses.  4.  Arteries  of  body  of  uterus.  5. 
Arteries  supp  ying  ovary.  Muscular  fasciculi. — 6,7.  Fibres  attached  to  vagina,  symphysis  pubis, 
and  sacro-iliac  joint.  8.  Muscular  fasciculi  from  uterus  and  broad  ligaments.  9,10,11,12.  Fasciculi 
attached  to  ovary  and  Fallopian  tubes. 


rings,  where  they  blend  with  the  cellular  tissue.  In  the  first  part  of 
their  course  the  muscular  fibres  are  solelv  of  the  unstriped  variety, 
but  soon  they  receive  striped  fibres  from  the  transversalis  muscles, 
and  the  columns  of  the  inguinal  ring,  which  surround  and  cover  the 
unstriped  muscular  tissue.  In  addition  to  these  structures  they  con- 
tain elastic  and  connective  tissue,  and  arterial,  venous,  and  nervous 
branches  ;  the  former  form  the  iliac  or  cremasteric  arteries,  the  latter 
the  genito-crural  nerve.  According  to  Mr.  Eainey  the  principal 
function  of  these  ligaments  is  to  draw  the  uterus  towards  the  sym- 
physis pubis  during  sexual  intercourse,  and  thus  to  favor  the  ascent 
of  the  semen. 

Vesico-uterine  Ligmneyits.— -The  vesico-uterine  ligaments  are  two 
folds  of  peritoneum  passing  in  front  from  the  lower  part  of  the  body 
of  the  uterus  to  the  fundus  of  the  bladder. 

Utero-sacral  Ligaments. — The  utero-sacral  ligaments  consist  of 
folds  of  peritoneum  of  a  crescentic  form,  with  their  concavities  look- 


THE  FEMALE  GENERATIVE  ORGANS.  63 

ing  inwards :  they  start  from  the  lower  part  of  the  posterior  surface 
of  the  uterus,  and  eurve  backwards  to  be  attached  to  tlie  third  and 
fourth  sacral  vcrtebraj.  Within  their  folds  exist  bundles  of  muscu- 
lar fibres,  continuous  with  those  of  the  uterus,  as  well  as  connective 
tissue,  vessels,  and  nerves.  The  experiments  of  Savage,  as  well  as 
of  other  anatomists,  show  that  these  ligaments  have  an  important 
influence  in  preventing  downward  displacement  of  the  womb. 

Alterations  durin;j  Pre(j7umcy. — During  pregnancy  all  these  liga- 
ments become  greatly  stretched  and  unfolded,  rising  out  of  the  pelvic 
cavity  and  accommodating  themselves  to  the  increased  size  of  the 
gravid  uterus  ;  and  they  again  contract  to  their  natural  size,  possibly 
through  the  agency  of  the  muscular  fibres  contained  within  them, 
after  delivery  has  taken  place. 

Fallopian  Tubes. — The  Fallopian  tubes,  the  homologues  of  the  vasa 
deferentia  in  the  male,  are  structures  of  great  ph3^siological  interest. 
They  serve  the  double  purpose  of  conveying  the  semen  to  the  ovary, 
and  of  carrying  the  ovule  to  the  uterus.     From  the  latter  function 
they  may  be  looked  on  as  the  excretory  ducts  of  the  ovaries ;  but, 
unlike  other  excretory  ducts,  they  are  movable,  so  that  they  may 
apply  themselves  to  the  part  of  the  ovaries  from  "which  the  ovule  is 
to  come;  and  so  great  is  their  mobility,  that  there  is  reason  to  believe 
that  a  Fallopian  tube  may  even  grasp  the  ovary  of  the  opposite  side. 
[This  has  been  established  by  a  case  where  impregnation  took  place 
in  an  ovary,  the  Fallopian  tube  corresponding  to  which  was  imper- 
vious and  immovable. — Ed.]     Each  tube  proceeds  from  the  upper 
angle  of  the  uterus  at  first  transversely  outwards,  and  then  down- 
wards, backwards,  and  inwards,  so  as  to  reach  the  neighborhood  of 
the  ovary.     In  the  first  part  of  its  course  it  is  straight,  afterwards  it 
becomes  flexuous  and  twisted  on  itself.     It  is  contained  in  the  upper 
part  of  the  broad  ligament,  where  it  may  be  felt  as  a  hard  cord.     It 
commences  at  the  uterus  by  a  narrow  opening,  admitting  only  the 
passage  of  a   bristle,  known  as  the  ostium  uterinum.     As  it  passes 
through  the  muscular  walls  of  the  uterus  the  tube  takes  a  somewhat 
curved  course,  and  opens  into  the  uterine  cavity  by  a  dilated  aper- 
ture.    From  its  uterine  attachment  the  tube  expands  gradually  until 
it  terminates  in  its  trurnpet-shaped  extremity;  just  before  its  distal 
end,  however,  it  again  contracts  slightly.     The  ovarian  end  of  the 
tube  is  surrounded  by  a  number  of  remarkable  fringe-like  processes. 
These  consist  of  longitudinal  membranous  fimbriae,  surrounding  the 
aperture  of  the  tube,  like  the  tentacles  of  a  polyp,  varying  consider- 
ably in  number  and  size,  and  having  their  edges  cut  and  subdivided. 
On  their  inner  surface  are  found  both  transverse  and  longitudinal 
folds  of  mucous  membrane,  continuous  with  those  lining  the  tube 
itself  (Fig.  30).     One  of  these  fimbrise  is  always  larger  and  more  de- 
veloped than  the  rest,  and  is  indirectly  united  to  the  surface  of  the 
ovary  by  a  fold  of  peritoneum  proceeding  from  its  external  surface. 
Its  under  surface  is  grooved  so  as  to  form  a  channel,  open  below. 
The  function  of  this  fringe-like  structure  is  to  grasp  the  ovary  during 
the  menstrual  nisus;  and  the  fimbria  which  is  attached  to  the  ovary 
would  seem  to  guide  the  tentacles  to  the  ovary  which  they  are  in- 


64 


ORGANS    CONCERNED    IN    PARTURITION. 


tended  to  seize.  One  or  more  supplementary  series  of  fimbriae  some- 
times exist,  which  have  an  aperture  of  communication  with  the  canal 
of  the  Fallopian  tube,  beyond  its  ovarian  extremity. 


Fig.  30. 


FaUopian  Tube  laid  open.     (After  Kichard.) 
a,b.  Uterine  portion  of  Tube,     c,  d.  Plicse  of  Mucous  Membrane,     e.  Tubo-ovarian  Ligaments  and 
Fringes.    /.  Ovary,    g/.  Bound  Ligaments. 

Their  Structure. — The  tubes  themselves  consist  of  peritoneal,  mus- 
cular, and  mucous  coats.  The  peritoneum  surrounds  the  tube  for 
three-fourths  of  its  calibre,  and  comes  into  contact  with  the  mucous 
lining  at  its  fimbriated  extremity,  the  only  instance  in  the  body 
where  such  a  junction  occurs.  The  muscular  coat  is  principallv 
composed  of  circular  fibres,  with  a  few  longitudinal  fibres  inter- 
spersed. Its  muscular  character  has  been  doubted  by  Robin  and 
Richard,  but  Farre  had  no  difiiciilty  in  demonstrating  the  existence 
of  muscular  fibres,  both  in  the  human  female  and  many  of  the  lower 
animals.  According  to  Robin  the  muscular  tissue  of  the  Fallopian 
tubes  is  entirely  distinct  from  that  of  the  uterus,  from  which  he 
describes  it  as  being  separated  by  a  distinct  cellular  septum.  The 
mucous  lining  is  thrown  into  a  number  of  remarkable  longitudinal 
folds,  each  of  which  contains  a  dense  and  vascular  fibrous  septum, 
Avith  small  muscular  fibres,  and  is  covered  with  columnar  and  ciliated 
epithelium.  The  apposition  of  these  produces  a  series  of  minute 
capillary  tubes,  along  which  the  ovules  are  propelled,  the  action  of 
the  cilia,  which  is  towards  the  uteras,  apparently  favoring  their 
progress. 

The  Ovaries. — The  ovaries  are  the  bodies  in  which  the  ovules  are 
formed,  and  from  which  they  are  expelled,  and  the  changes  going  on 
in  them  in  connection  with  the  process  of  ovulation,  during  the 
whole  period  between  the  establishment  of  puberty  and  the  cessation 
of  menstruation,  have  an  enormous  influence  on  the  female  economy. 
Normally,  the  ovaries  are  two  in  number;  in  some  exceptional  cases 
a  supplementary  ovary  has  been  discovered ;  or  they  may  be  entirely 


THE  FEMALE  GENERATIVE  ORGANS. 


65 


absent.  They  are  placed  in  the  posterior  fold  of  tlie  broad  ligament, 
usually  below  the  brim  of  the  pelvis,  behind  the  Fallopian  tuljes,  the 
left  in  front  of  the  rectum,  the  right  in  front  of  some  coils  of  the 
small  intestine.  Their  situation  varies,  however,  very  much  under 
different  circumstances,  so  that  they  can  scarcely  be  said  to  have  a 
fixed  and  normal  position.  In  pregnancy  they  rise  into  the  abdomi- 
nal cavity  with  the  enlarging  uterus ;  and  in  certain  conditions  they 
are  dislocated  downwards  into  Douglas's  space,  where  they  may  be 
felt  through  the  vagina  as  rounded  and  Yery  tender  bodies. 

Their  Connections. — The  folds  of  the  broad  ligament,  between  which 
the  ovaries  are  placed,  form  for  them  a  kind  of  loose  mesentery. 
Each  of  them  is  united  to  the  upper  angle  of  the  uterus  by  a  special 
ligament  called  the  utero-ovarian.  This  is  a  rounded  band  of  organic 
muscular  fibres,  about  an  inch  in  length,  continuous  with  the  super- 
ficial muscular  fibres  of  the  posterior  wall  of  the  uterus,  and  attached 
to  the  inner  extremity  of  the  ovary.  It  is  surrounded  by  peritoneum, 
and  through  it  the  muscular  fibres,  which  form  an  important  integral 
part  in  the  structure  of  the  ovaries,  are  conveyed  to  them.  The 
ovary  is  also  attached  to  the  fimbriated  extremity  of  the  Fallopian 
tube  in  the  manner  already  described. 

The  ovary  is  of  an  irregular  oval  shape  (Fig.  31),  the  upper  bor- 
der being  convex,  the  lower — through  which  the  vessels  and  nerves 
enter — -being  straight.  The  anterior  surface,  like  that  of  the  uterus, 
is  less  convex   than  the  posterior.      The  outer  extremity  is  more 


A  A.  Ovary  enlarged  under  Menstrual  Nisus.      b.  Ripe  Follicle  projecting  on  its  surface. 
a,  a,  a.  Traces  of  previously  ruptured  Follicle. 

rounded  and  bulbous  than  the  inner,  which  is  somewhat  pointed  and 
eventually  lost  in  its  proper  ligament.  By  these  peculiarities  it  is 
possible  to  distinguish  the  left  from  the  right  ovary,  after  they  have 
been  removed  from  the  body.  The  ovary  varies  much  in  size  under 
different  circumstances.  On  an  average,  in  adult  life,  it  measures 
from  one  to  two  inches  in  length,  three-quarters  of  an  inch  in  width, 
and  about  half  an  inch  in  thickness.     It  increases  greatlv  in  size 


QQ  ORGANS    CONCERNED    IN    PA '^TURITION . 

during  each  menstrual  period ;  a  fact  whicli  lias  been  demonstrated 
in  certain  cases  of  ovarian  hernia,  where  the  protruded  ovary  has 
been  seen  to  swell  as  menstruation  commenced  ;  also  during  preg- 
nancy, when  it  is  said  to  be  double  its  usual  size.    After  the  change  of 
life  it  atrophies,  and  becomes  rough  and  wrinkled  on  its  surface.    Be- 
fore puberty,  the  surface  of  the  ovary  is  smooth  and  polished,  and  of 
a  whitish  color.    After  menstruation  commences,  its  surface  becomes 
scarred  by  the  rupture  of  the  Graafian  follicles  (Fig.  31,  a  a),  each  of 
which  leaves  a  little  linear  or   striated  cicatrix,  of  a  brownish  color; 
and  the  older  the  patient  the  greater  are  the  number  of  these  cicatrices. 
Structure. — The  structure  of  the  ovary  has  been  made  the  subject 
of  many  important  observations.      It  has  an  external  covering  of 
epithelium,  originally  continuous  with    the    peritoneum,  called   by 
some  the  germ -epithelium,  in  consequence  of  the  ovules  being  formed 
from  it  in  early  foetal  life.    In  the  adult  it  is  separated  from  the  peri- 
toneum at  the  base  of  the  organ  by  a  circular  white  line,  and  it  con- 
sists of  columnar    epithelium,  diilering    only  from    the  epithelium 
lining  the  Fallopian  tubes,  with  which  it  is  sometimes  continuous 
through  the  attached  fimbria  uniting  the  tube  and  the  ovai'y,  in  being- 
destitute  of  cilia.     Immediately  beneath  this  covering  is  the  dense 
coat  known  as  the  tunica  alhu(/i7iea^  on  account  of  its  whitish  color. 
It  consists  of  short  connective-tissue  fibres,  arranged  in  laminte,  among 
which  are  interspersed  fusiform  muscular  fibres.    At  the  point  where 
the  vessels  and  nerves  enter  the  ovary  this  membrane  is  raised  into 
a  ridge,  which  is  continuous  with  the  utero- ovarian  ligament.     The 
tunica  albuginea  is  so  intimately  blended  with  the  stroma  of  the 
ovary,  as  to  be  inseparable  on  dissection  ;  it  does  not,  however,  exist 
as  a  distinct  lamina,  but  is  merely  the  external  part  of  the  proper 
structure  of  the  ovary,  in  which   more  dense  connective  tissue  is 
developed  than  elsewhere. 

TJie  Stroma. — On  making  a  longitudinal  section  of  the  ovary  (Fig. 
32),  it  will  be  seen  to  be  composed  of  two  parts,  the  more  internal 

of  which  is  of  a  reddish  color  from  the  num- 
FiG.  32.  ber  of  vessels  that  ramify  in  it,  and  is  called 

the  mednllary  or  vascular  zone  ;  while  the 
external,  of  a  whitish  tint,  receives  the 
name  of  the  cortical  or  parenchymatous 
substance.  The  former  consists  of  loose 
connective  tissue  interspersed  with  elastic, 
and  a  considerable  number  of  muscular 
fibres.  According  to  Eouget^  and  His^ 
the  muscular  structure  forms  the  greater 
part  of  the  ovarian  stroma.  The  latter  de- 
scribes it  as  consisting  essentially  of  inter- 
Lo„,ntudinai  section  of  ad.it  wovcu  muscular  fibrcs,  which  he  tcrms 
ovary.   (After  Farr« )  the  "  fusifomi  tissuc,"  and  which    hc    be- 

lieves to  be  continuous  with  the  muscular 
layers  of  the  ovarian  vessels.  The  former  believes  that  the  mus- 
cular fasciculi  accompany  the  vessels  in  the  form  of  sheaths,  as  in 

'  Journal  de  Physiol,  i.  p.  737-  ^  Scliultze's  Arch.  f.  Mikrocop.  Aiiat.  1865. 


THE  FEMALE  GENERATIVE  ORGANS, 


67 


erectile  tissues.  Both  attribute  to  the  muscular  tissues  an  important 
influence  in  the  expulsion  of  the  ovules,  and  in  the  rupture  of  the 
Graafian  follicles.  Waldcyer  and  other  writers,  however,  do  not 
consider  it  to  be  so  extensively  developed  as  Eouget  and  His  believe. 
The  cortical  substance  is  the  more  important  as  that  in  which  the 
Graafian  follicles  and  ovules  are  formed.  It  consists  of  interlaced 
fibres  of  connective  tissue,  containing  a  large  number  of  nuclei.  The 
muscular  fibres  of  the  medullary  substance  do  not  seem  to  penetrate 
into  it  in  man.  In  it  are  found  the  Graafian  follicles,  which  exist  in 
enormous  numbers  from  the  earliest  periods  of  life,  and  in  all  stages 
of  development  (Fig.  38). 

Fig.  33. 


Section  through  the  Cortical  part  of  the  Ovary. 
«.    Surface  epithelium,     ss.  Ovarian  Stroma.      11.  Large-sized  Graafian  Follicles.     2  2.  Middle- 
sized, aud  3  3,  Small  sized  Graafian  Follicles,     o.  Ovule 'within  Graafian  Follicle,    vv.  Bloodvessels 
in  the  Stroma,    g.  Cells  of  the  Memhrana  Granulosa.     (After  Turner.) 

The  Graafian  Follicles. — According  to  the  researches  of  Pfliiger, 
Waldeyer,  and  other  German  writers,  the  Graafian  follicles  are 
formed  in  early  foetal  life  by  cylindrical  inflections  of  the  epithelial 
covering  of  the  ovary,  which  dip  into  the  substance  of  the  gland. 
These  tubular  filaments  anastomose  with  each  other  and  in  them 
are  formed  the  ovules,  which  are  originally  the  epithelial  cells  lining 
the  tubes.  Portions  become  shut  off  from  the  rest  of  the  filaments, 
and  form  the  Graafian  follicles.  The  ovules,  on  this  view,  are  highly 
developed  epithelial  cells,  originally  derived  from  the  surface  of  the 
ovary,  and  not  developed  in  its  stroma.  These  tubular  filaments 
disappear  shortly  after  birth,  but  they  have  recently  been  detected 
by  Slavyansky^  in  the  ovaries  of  a  woman  thirty  years  of  age. 
These  observations  have  been  modified  by  ]Dr^!Foulis.^     He  recog- 

•  Aunales  de  Gynak.  Feb.  1871. 
2  Proceedings  of  the  Royal  Soc.  of  Edinb. 
Phys.  vol.  xiii.,  1870. 


A 


April, '18 
Vmri 


of  Anat.  and 
'i 


^''n  inn 


68 


ORGANS    CONCERNED    IN    PARTURITION, 


nizes  the  origin  of  the  ovules  from  the  germ-epithelium  coveriug 
the  surface  of  the  ovary,  which  is  itself  derived  from  the  Wolffian 
body.  He  believes  all  the  ovules  to  be  formed  from  the  germ-epi- 
thelium corpuscles,  which  become  embedded  in  the  stroma  of  the 
ovary,  by  the  outgrowth  of  processes  of  vascular  connective  tissue, 
fresh  germ-epithelial  corpuscles  being  constantly  produced  on  the 
surface  of  the  organ  up  to  the  age  of  2J  years,  to  take  the  place  of 
those  already  embedded  in  its  stroma.  He  believes  the  Graafian 
follicles  to  be  formed  by  the  growth  of  delicate  processes  of  connec- 
tive tissue  between  and  around  the  ovules,  but  not  from  tubular 
inflections  of  the  epithelium  covering  the  gland,  as  described  by 
Waldeyer  (Fig.  34).     This  view  is  supported  by  the  researches  of 

Fig.  34. 


Vertical  Section  through  the  Ovaiy  of  the  Human  Fcetus. 
gg.  Germ-epitLelium,  with  oo,  developing  ovules  in  it.    s  s.  Ovarian  Stroma,  containing  cee, 
Tusiform  Connective  tissue  Corpuscles,    'wu.  Capillary  Bloodvessels.     In  the  centre  of  the  Figure 
an  Involution  of  the  Germ-epithelium  is  shown;  and  at  the  left  lower  side  a  Primordial  Ovule,  with 
the  Connective-tissue  Corpuscles  ranging  themselves  round  it.     (After  Foulis.) 

Balfour,^  who  arrives  at  the  conclusion  that  the  whole  egg- contain- 
ing part  of  the  ovary  is  really  the  thickened  germinal  epithelium, 
broken  up  into  a  kind  of  mesh  work  bv  growths  of  vascular  stroma. 
According  to  this  theory  Pflliger's  tubular  filaments  are  merely  trabe- 
culse  of  germinal  epithelium,  modified  cells  of  which  become  de- 
veloped into  ova. 

The  greater  proportion  of  the  Graafian  follicles  are  only  visible 
with  the  high  powers  of  the  microscope,  but  those  which  are  ap- 
proaching maturity  are  distinctly  to  be  seen  by  the  naked  eye.  The 
quantity  of  these  follicles  is  immense.  Foulis  estimates  that  at  birth 
each  human  ovary  contains  not  less  than  30,000.  No  fresh  follicles 
appear  to  be  found  after  birth,  and  as  development  goes  on  some 
only  grow,  and,  by  pressure  on  the  others,  destroy  them.  Of  those 
that  grow  of  course  only  a  few  ever  reach  maturity;  they  are  scat- 
tered through  the  substance  of  the  ovary,  some  developing  in  the 


•  F.  M.  Balfonr.  "Structure  and  Development  of  Vertebrate  Ovary." 
Journal  of  Microscopical  Science,  vol.  xviii.,  1878. 


Quarterly 


THE    FEMALE    GENERATIVE    OllGANS, 


69 


Stroma,  others  on  the  surface  of  the  organ,  where  they  eventually 
burst,  and  are  discharged  into  the  Fallopian  tube. 

Structure. — A  ripe  Graafian  follicle  has  an  external  investing  mem- 
brane (Fig.  35),  which  is  generally  described  as  consisting  of  two 


Fig.  35. 


Diagrammatic  Section  of  Graafian  Foricle. 

1.  Ovum.    2.  Membrana  granulosa.     3.  External  membrane  of  Graafian  follicle.     4.  Its  vessels. 
5.  Ovarian  stroma.     6.  Cavity  of  Graafian  follicle.     7.  External  covering  of  ovary. 

distinct  layers ;  the  external,  or  tunica  fibrosa^  highly  vascular  and 
formed  of  connective  tissue  ;  the  internal,  or  tunica  propria^  composed 
of  young  connective  tissue,  containing  a  large  number  of  fusiform 
or  stellate  cells,  and  numerous  oil-globules.  These  layers,  however, 
appear  to  be  essentially  formed  of  condensed  ovarian  stroma.  Within 
this  capsule,  is  the  epithelial  lining  called  the  memhrana  granulosa^ 
consisting  of  stratified  columnar  epithelial  cells,  which,  according  to 
Foulis,  are  originally  formed  from  the  nuclei  of  the  fibro-nuclear 
tissue  of  the  stroma  of  the  ovary.  At  one  part  of  the  circumference 
of  the  ovisac  is  situated  the  ovule,  around  which  the  epithelial  cells 
are  congregated  in  greater  quantity,  constituting  the  projection  known 
as  the  discus  proligerus.  The  remainder  of  the  cavity  of  the  follicle 
is  filled  vfith  a  small  quantity  of  transparent  fluid,  the  liquor  follicuU^ 
traversed  by  three  or  four  minute  bands,  the  retinacula  of  Barry, 
which  are  attached  to  the  opposite  walls  of  the  follicular  cavity,  and 
apparently  serve  the  purpose  of  suspending  the  ovule  and  main- 
taining it  in  a  proper  position.  In  many  young  follicles  this  cavity 
does  not  at  first  exist,  the  follicle  being  entirely  filled  by  the  ovule. 
According  to  Waldeyer,  tlie  liquor  folliculi  is  formed  by  the  disinte- 
gration of  the  epithelial  cells,  the  fluid  thus  produced  collecting,  and 
distending  the  interior  of  the  follicle. 

Ovule. — The  ovule  is  attached  to  some  part  of  the  internal  surface 
of  the  Graafian  follicle.  It  is  a  rounded  vesicle  about  ^l-^  of  an  inch 
in  diameter,  and  is  surrounded  by  a  layer  of  columnar  cells,  distinct 
from  those  of  the  discus  proligerus  in  which  it  lies.  It  is  invested 
by  a  transparent  elastic  membrane,  the  zona  pellucida^  or  vitelline 
membrane.  In  most  of  the  lower  animals  the  zona  pellucida  is  per- 
forated  by  numerous  very   minute  pores,   only  visible  under  the 


70 


ORGANS    CONCERNED    IN    PARTURITION. 


highest  powers  of  the  microscope ;  in  others  there  is  a  distinct  aper- 
ture of  a  larger  size,  the  micropyle,  allowing  the  passage  for  the 
spermatozoa  into  the  interior  of  the  ovule.  It  is  possible  that  similar 
apertures  may  exist  in  the  human  ovule,  but  they  have  not  been 
demonstrated.  Within  the  zona  pellucida  some  embryologists  de- 
scribe a  second  hne  membrane,  the  existence  of  which  has  been 
denied  by  Bischoff.  The  cavity  of  the  ovule  is  filled  with  a  viscid 
yellow  fluid,  the  yelk^  containing  numerous  grannies.  It  entirely 
lills  the  cavity,  to  the  walls  of  which  it  is  non-adherent.  In  the 
centre  of  the  yelk  in  young,  and  at  some  portion  of  its  periphery  in 
mature  ovules,  is  situated  the  germinal  vesicle^  which  is  a  clear  cir- 
cular vesicle,  refracting  light  strongly,  and  about  gi^th  of  a  line  in 
diameter.  It  contains  a  few  granules,  and  a  nucleolus,  or  yerminal 
spot,  which  is  sometimes  double. 

From  within  outwards,  therefore,  we  find: — 

1.  The  germinal  spot;  round  this 

2.  The  germinal  vesicle,  contained  in 

3.  The  yelk,  which  is  surrounded  by  the 

4.  Zona  pellucida,  with  its  layers  of  columnar  epithelial  cells. 
These  constitute  the  ovule. 

The  ovule  is  contained  in — 

The  Graafian  follicle,  and  lies  in  that  part  of  its  epithelial  lining 
called  the — 

Discus  ■proligerus,  the  rest  of  the  follicle  being  occupied  by  the 
liquor  follicidi.  Eound  these  we  have  the  epithelial  lining  or  mem- 
hrana  granulosa,  and  the  external  coat  consisting  of  the  tunica  pro- 
pria and  the  tunica  fibrosa. 

Vessels  and  Nerves  of  the  Of  ar?/.— The  vascular  supply  of  the  ovary 
is  complex.     The  arteries  enter  at  the  hilum,  penetrating  the  stroma 

Fig.   3G. 


Bulb  of  Ovary. 

p.  Uterus,    o.  Ovary  and  utero-ovarian  ligament,    r.  Fallopian  tube.    1.  Utero-ovarian  vein. 

2.  Pampiniform  ovarian  plexus.    3.  Commencemeut  of  spermatic  vein. 


in  a  spiral  curve,  and  are  ultimately  distributed  in  a  rich  capillary 
plexus  to  the  follicles.  The  large  veins  unite  freely  with  each  other, 
and  form  a  vascular  and  erectile  plexus,  continuous  with  that  sur- 
rounding the  uterus,  ^called  the  bulb  of  the  ovary  (Fig.  36).  Lym- 
phatics and  nerves  exist,  but  their  mode  of  termination  is  unknown. 


THE  FEMALE  GENERATIVE  ORGANS.  71 

The  Mammary  Glands. — To  complete  tlie  consideration  of  the 
generative  organs  o'i  the  female  we  must  study  the  maribmary  yknals, 
which  secrete  the  fluid  destined  to  nourish  the  child.  In  the  human 
subject  they  are  two  in  number,  and  instead  of  being  placed  upon  the 
abdomen,  as  in  most  animals,  they  are  situated  on  eitlier  side  of  the 
sternum,  over  the  pectoralis  major  muscles,  and  extend  from  the  third 
to  the  sixth  ribs.  This  position  of  tlie  glands  is  obviously  intended 
to  suit  the  erect  position  of  the  female  in  suckling.  They  are  con- 
vex anteriorly,  and  flattened  posteriorly  where  they  rest  on  the 
muscles.  They  vary  greatly  in  size  in  different  subjects,  chiefly  in 
proportion  to  the  amount  of  adipose  tissue  they  contain.  In  man, 
and  in  girls,  previous  to  puberty,  they  are  rudimentary  in  structure  ; 
wiiile  in  pregnant  women  they  increase  greatly  in  size,  the  true 
glandular  structures  becoming  much  hypertrophied.  Anomalies  in 
shape  and  position  are  sometimes  observed.  SupiDlementary  mammte, 
one  or  more  in  number,  situated  on  the  upper  portion  of  the  mam- 
mte,  are  sometimes  met  with,  identical  in  structure  with  the  normally 
situated  glands;  or,  more  commonlj^,  an  extra  nipple  is  observed  by 
the  side  of  the  normal  one.  In  some  races,  especially  the  African, 
the  mammas  are  so  enormously  developed,  that  the  mother  is  able  to 
suckle  her  child  over  her  shoulder. 

Their  Structure. — The  skin  covering  the  gland  is  soft  and  supple, 
and  during  pregnancy  often  becomes  covered  with  fine  white  lines, 
while  large  blue  veins  may  be  observed  coursing  over.  Underneath 
it  is  a  quantity  of  connective  tissue,  containing  a  considerable  amount 
of  fat,  which  extends  between  the  true  glandular  structure.  This  is 
composed  of  from  fifteen  to  twenty  lobes,  each  of  Avliich  is  formed 
of  a  number  of  lobules.  The  lobules  are  produced  by  the  aggrega- 
tion of  the  terminal  acini  in  which  the  milk  is  formed.  The  acini 
are  minute  culs-de-sac  opening  into  little  ducts,  which  unite  with 
each  other  until  they  form  a  large  duct  for  each  lobule ;  the  ducts  of 

Fig.  37 


2.  LobuU  of  the  mammary  gland. 


each  lobule  unite  with  each  other,  until  they  end  in  a  still  larger  duct 
common  to  each  of  the  fifteen  or  twenty  lobes  into  which  the  gland 
is  divided,  and  eventually  open  on  the  surface  of  the  nipple.  These 
terminal  canals  are  known  as  the  c/aIacto2:)horus  ducts  (Fig.  37). 
They  become  widely  dilated  as  they  approach  the  nipple,  so  as  to 


72  ORGANS    CONCERNED    IN    PARTURITION. 

form  reservoirs  in  whicli  milk  is  stored  until  it  is  required,  but  when 
they  actually  enter  the  nipple  they  again  contract.  Sometimes  they 
give  off  lateral  branches,  but,  according  to  Sappey,  they  do  not  anas- 
tomose with  each  other,  as  some  anatomists  have  described.  These 
excretory  ducts  are  composed  of  connective  tissue,  with  numerous 
elastic  fibres  on  their  external  surface.  Sappey  and  Eobin  describe 
a  layer  of  muscular  fibres,  chiefly  developed  near  their  terminal 
extremities.  They  are  lined  with  columnar  epithelium,  continuous 
with  that  in  the  acini;  and  it  is  by  the  distension  of  its  cells  with 
fatty  matter,  and  their  subsequent  bursting,  that  the  milk  is  formed. 

Nipple. — The  nipple  is  the  conical  projection  at  the  summit  of  the 
mamma,  and  it  varies  in  size  in  different  women.  Not  very  unfre- 
quently,  from  the  continuous  pressure  to  which  it  has  been  subjected 
by  the  dress,  it  is  so  depressed  below  the  surface  of  the  skin  as  to 
prevent  lactation.  It  is  generally  larger  in  married  than  in  single 
women,  and  increases  in  size  during  pregnancy.  Its  surface  is  covered 
with  numerous  papillae,  giving  it  a  rngous  aspect,  and  at  their  bases 
the  orifices  of  the  lactiferous  ducts  open.  Here  are  also  the  openings 
of  numerous  sebaceous  follicles,  which  secrete  an  unctuous  material 
supposed  to  protect  and  soften  the  integument  during  lactation. 
Beneath  the  skin  are  muscular  fibres,  mixed  with  connective  and 
elastic  tissues,  vessels,  nerves,  and  Ij^mphatics.  When  the  nipple  is 
irritated  it  contracts  and  hardens,  and  by  some  this  is  attributed  to 
its  erectile  properties.  The  vascularity,  however,  is  not  great,  and 
it  contains  no  true  erectile  tissue :  the  hardening  is,  therefore,  due 
to  muscular  contraction.  Surrounding  the  nipple  is  the  areola^  of  a 
pink  color  in  virgins,  becoming  dark  from  the  development  of  pig- 
ment cells  during  pregnancy,  and  always  remaining  somewhat  dark 
after  childbearing.  On  its  surface  are  a  number  of  prominent  tuber- 
cles, sixteen  to  twenty  in  number,  which  also  become  largely  de- 
veloped during  gestation.  They  are  supposed  by  some  to  secrete 
milk,  and  to  open  into  the  lactiferous  tubes  ;  most  probably  they  are 
composed  of  sebaceous  glands  only.  Beneath  the  areolar  is  a  circular 
band  of  muscular  fibres,  the  object  of  which  is  to  compress  the  lactif- 
erous tubes  which  run  through  it,  and  thus  to  favor  the  expulsion 
of  their  contents.  The  mammae  receive  their  blood  from  the  internal 
mammary  and  intercostal  arteries,  and  they  are  richly  supplied  with 
lymphatic  vessels,  which  open  into  the  axillary  glands.  The  nerves 
are  derived  from  the  intercostal  and  thoracic  branches  of  the  brachial 
plexus. 

The  secretion  of  milk  in  women  who  are  nursing  is  accompanied 
by  a  peculiar  sensation,  as  if  milk  were  rushing  into  the  breast, 
called  the  "  draught,"  which  is  excited  by  the  efforts  of  the  child  to 
suck,  and  by  various  other  causes.  The  symjiathctic  relations  be- 
tween the  mammae  and  the  uterus  are  very  well  marked,  as  is  shown 
in  the  unimpregnated  state  by  the  fact  of  the  frequent  occurrence  of 
sympathetic  pains  in  the  breast  in  connection  with  various  uterine 
diseases,  and,  after  delivery,  by  the  well-known  fact  that  suction  pro- 
duces reflex  contraction  of  the  uterus,  and  even  severe  after-pains. 


OVULATION  AND  MENSTRUATION.  73 


CIIAPTEE    III. 

OVULATION   AXD   MENSTRUATIOX. 

Functions  of  the  Ovary. — The  main,  function  of  the  ovary  is  to 
supply  the  female  generative  element,  and  to  expel  it,  when  ready 
for  impregnation  into  the  Fallopian  tube,  along  Avhich  it  passes  into 
the  uterus.  This  process  takes  place  spontaneous  in  all  viviparous 
animals,  and  without  the  assistance  of  the  male.  In  the  lower  animals 
this  periodical  discharge  receives  the  name  of  the  oestrus  or  rut,  at 
which  time  only  the  female  is  capable  of  impregnation  and  admits 
the  approach  of  the  male.  In  the  human  female  the  periodical  dis- 
charge of  the  ovule,  in  all  probability,  takes  place  in  connection  with 
menstruation,  wdiich  may  therefore  be  considered  to  be  the  analogue 
of  the  rut  in  animals.  After  each  menstrual  period  Graafian  folli- 
cles undergo  changes  which  prepare  them  for  rupture  and  the  dis- 
charge of  their  contained  ovules.  After  rupture,  certain  changes 
occur  which  have  for  their  object  the  healing  of  the  rent  in  the 
ovarian  tissue  through  Avhich.  the  ovule  has  escaped,  and  the  filling 
up  of  the  cavity  in  which  it  was  contained.  This  results  in  the  for- 
mation of  a  peculiar  body  in  the  substance  of  the  ovary,  called  the 
corpus  luteum  which  is  essentially  modified  should  pregnancy  occur, 
and  is  of  great  interest  and  importance.  During  the  whole  of  the 
childbearing  epoch  the  periodical  maturation  and  rupture  of  the 
Graafian  follicles  are  going  on.  If  impregnation  does  not  take  place, 
the  ovules  are  discharged  and  lost ;  if  it  does,  ovulation  is  stopped, 
as  a  general  rule,  during  gestation  and  lactation. 

Theory  of  Menstruation. — -This,  broadly  speaking,  is  an  outline  of 
the  modern  theory  of  menstruation  which  was  first  broached  in  the 
year  1821  by  Dr.  Power,  and  subsequently  elaborated  by  Negrier, 
Bischoff,  Raciborski,  and  many  other  writers.  Although  the  se- 
quence of  events  here  indicated  may  be  taken  to  be  the  rule,  it  must 
be  remembered  that  it  is  one  subject  to  many  exceptions,  for  un- 
doubtedly ovulation  may  occur  without  its  outward  manifestation, 
menstruation,  as  in  cases  in  which  impregnation  takes  place  during 
lactation  or  before  menstruation  has  been  established,  of  which  many 
examples  are  recorded.  These  exceptions  have  led  some  modern 
writers  to  deny  the  ovular  theory  of  menstruation,  and  their  views 
will  require  subsequent  consideration. 

In  order  to  understand  the  subject  properly  it  will  be  necessary  to 
study  the  sequence  of  events  in  detail. 

Changes  in  the  Graafian  Follicle. — The  changes  in  the  Graafian 
follicle  which  are  associated  with  the  discharge  of  the  ovules  com- 
prise— 1.  Maturation.  As  the  period  of  puberty  approaches  a  cer- 
6 


74  ORGANS    CONCERNED    IN    PARTURITION. 

tain  number  of  tlie  Graafian  follicles,  fifteen  to  twenty  in  number, 
increase  in  size,  and  come  near  the  surface  of  the  ovary.  Amongst 
these  one  becomes  especially  developed,  preparatory  to  rupture,  and 
upon  it  for  the  time  being  all  the  vital  energy  of  the  ovary  seems  to 
be  concentrated.  A  similar  change  in  one,  sometimes  in  more  than 
one,  follicle  takes  place  periodically  during  the  whole  of  the  child- 
bearing  epoch,  in  connection  with  each  menstrual  period,  and  an 
examination  of  the  ovary  will  show  several  follicles  in  different  stages 
of  development.  The  maturing  follicle  becomes  gradually  larger, 
until  it  forms  a  projection  on  the  surface  of  the  ovarj^,  from  five  to 
seven  lines  in  breadth,  but  sometimes  even  as  large  as  a  nut  (Fig. 
31).  This  growth  is  due  to  the  distension  of  the  follicle  by  the  in- 
crease of  its  contained  fluid,  which,  causes  it  so  to  press  upon  the 
ovarian  structures  covering  it,  that  they  become  thinned,  separated 
from  each  other,  and  partially  absorbed,  until  they  eventually  readily 
lacerate.  The  follicle  also  becomes  greatly  congested,  the  capillaries 
coursing  over  it  become  increased  in  size  and  loaded  with  blood, 
and  being  seen  through  the  attenuated  ovarian  tissue,  give  it,  when 
mature,  a  bright  red  color.  At  this  time  some  of  these  distended 
capillaries  in  its  inner  coat  lacerate,  and  a  certain  quantity  of  blood 
escapes  into  its  cavity.  This  escape  of  blood  takes  place  before 
rupture,  and  seems  to  have  for  its  principal  object  the  increase  of  the 
tension  of  the  follicle,  of  which  it  has  been  termed  the  menstruation. 
Pouchet  was  of  opinion  that  the  blood  collects  behind  the  ovule,  and 
carries  it  up  to  the  surface  of  the  follicle.  By  these  means  the  follicle 
is  more  and  more  distended,  until  at  last  it  ruptures  either  sponta- 
neously or,  it  may  be,  under  the  stimulus  of  sexual  excitement. 
Whether  the  laceration  takes  place  during,  before,  or  after  the  men- 
strual discharge  is  not  j'^et  positively  known :  from  the  results  of 
post-mortem  examination  in  a  number  of  women  who  died  shortly 
before  or  after  the  period,  Williams  believes  that  the  ovules  are  ex- 
pelled before  the  monthly  flow  commences.^  In  order  that  the  ovule 
may  escape,  the  laceration  must,  of  course,  involve  not  only  the  coats 
of  the  Graafian  follicles,  but  also  the  superincumbent  structures. 

Laceration  seems  to  be  aided  by  the  growth  of  the  internal  layer 
of  the  follicle,  which  increases  in  thickness  before  rupture,  and 
assumes  a  characteristic  yellow  color  from  the  number  of  oil-globules 
it  then  contains.  It  is  also  greatly  facilitated,  if  it  be  not  actually 
produced,  by  the  turgescence  of  the  ovary  at  each  menstrual  period, 
and  by  the  contraction  of  the  muscular  fibres  in  the  ovarian  stroma. 
As  soon  as  the  rent  in  the  follicular  Avails  is  produced,  the  ovule  is 
discharged,  surrounded  by  some  of  the  cells  of  the  membrana  granu- 
losa, and  is  received  into  the  fimbriated  extremity  of  the  Fallopian 
tube,  which  grasps  the  ovary  over  the  site  of  the  rupture.  By  the 
vibratile  cilia  of  its  epithelial  lining,  it  is  then  conducted  into  the 
canal  of  the  tube,  along  which  it  is  propelled,  partly  by  ciliary  action 
and  partly  by  muscular  contraction  in  the  walls  of  the  tube. 

Obliteration  of  the  Graafian  Follicle. — After  the  ovule  has  escaped, 

>  Proceedings  of  the  Royal  Society,  1875. 


OVULATION    AND    MENSTRUATION. 


7o 


certain  characteristic  claanges  occur  in  the  empty  Graafian  follicle, 
which  have  fur  their  object  its  cicatrization  and  obliteration.  Tliere 
are  great  differences  in  the  changes  which  occur  when  impregnation 
has  followed  the  escape  of  the  ovule,  and  they  are  then  so  remarkable 
that  they  have  been  considered  certain  signs  of  pregnancy.  Tiiey 
are,  however,  differences  of  degree  rather  than  of  kind.  It  will  be 
well,  however,  to  discuss  them  separately. 

Changes  undergone  by  the  Follicle  where  Impregnation  does  not  occur. 
— As  soon  as  the  ovule  is  discharged,  the  edges  of  the  rent  through 
which  it  has  escaped  become  agglutinated  by  exudation,  and  the  fol- 
licle shrinks,  as  is  generally  believed,  by  the  inherent  elasticity  of  its 
internal  coat,  but  according  to  Robin,  who  denies  the  existence  of 
this  coat,  from  compression  by  the  muscular  fibres  of  the  ovarian 
stroma.  In  proportion  to  the  contraction  that  takes  place,  the  inner 
layer  of  the  follicle,  the  cells  of  which  have  become  greatly  hyper- 
trophied  and  loaded  with  fat  granules  previous  to  rupture,  is  thrown 
into  numerous  folds.  The  greater  the  amount  of  contraction  the 
deeper  these  folds  become,  giving  to  a 
section  of  the  follicle  an  appearance 
similar  to  that  of  the  convolutions  of 
the  brain  (Fig.  38).  These  folds  in  the 
human  subjecb  are  generally  of  a  bright 
yellow  color,  but  in  some  of  the  mam- 
malia they  are  of  a  deep  red.  The  tint 
was  formerly  ascribed  by  Raciborski  to 
absorption  of  the  coloring  matter  of  the 
blood-clot  contained  in  the  follicular 
cavity,  a  theory  he  has  more  recently 
abandoned  in  favor  of  the  view  main- 
tained by  Ooste  that  it  is  due  to  the  in- 
herent color  of  the  cells  of  the  lining- 
membrane  of  the  follicle,  which,  though 
not  well  marked  in  a  single  cell,  becomes 
very  apparent  e7i  masse.  The  existence 
of  a  contained  blood-clot  is  also  denied 
by  the  latter  physiologist,  except  as  an  unusual  pathological  con- 
dition ;  and  he  describes  the  cavity  as  containing  a  gelatinous  and 
plastic  fluid,  which  becomes  absorbed  as  contraction  advances.  The 
more  recent  researches  of  Dalton,i  however,  show  the  existence  of  a 
central  blood  clot  in  the  cavity  of  the  follicle,  and  he  considers  its 
occasional  absence  to  be  connected  with  disturbance  or  cessation  of 
the  menstrual  function.  The  folds  into  which  the  membrane  has 
been  thrown  continue  to  increase  in  size,  from  the  proliferation  of 
their  cells,  until  they  unite  and  become  adherent,  and  eventually  fill 
the  follicular  cavity.  By  the  time  that  another  Graafian  follicle  is 
matured  and  ready  for  rupture  the  diminution  has  advanced  con- 
siderably, and  the  empty  ovisac  is  reduced  to  a  very  small  size.  The 
cavity  is  now  nearly  obliterated,  the  yellow  color  of  the  convolutions 


Section  of  ovary,  showing  corpus  lute- 
urn  three  weeks  after  menstruation. 
(After  Dalton.) 


'  Report  on  the  Corpus  Luteum.     American  Gyn^c.  Trans,  vol.  ii.,  1878. 


76 


ORGANS    CONCERNED    IN    PARTURITION. 


is  altered  into  a  whitish  tint,  and  on  section  the  corpus  hiteiim  has 
the  appearance  of  a  compact  white  stellate  cicatrix,  which  generally 
disappears  in  less  than  forty  days  from  the  period  of  rupture.  The 
tissue  of  the  ovary  at  the  site  of  laceration  also  shrinks,  and  this, 
aided  by  the  contraction  of  the  follicle,  gives  rise  to  one  of  those  per- 
manent pits  or  depressions  which  mark  the  surface  of  the  adult  ovary. 
Slavyansky^  has  recently  shown  that  only  a  few  of  the  immense 
number  of  Graafian  follicles  undergo  these  alterations.  The  greater 
proportion  of  them  seem  never  to  discbarge  their  ovules,  but,  after 
increasing  in  size,  undergo  retrogressive  changes  exactly  similar  in 
their  nature,  but  to  a  much  less  extent,  to  those  which  result  in  the 
formation  of  a  corpus  luteum.  The  sites  of  these  may  afterwards  be 
seen  as  minute  striae  in  the  substance  of  the  ovary. 

Changes  undergone  hy  the  Follicle  ivhen  Impregnation  has  take7i 
place. — Should  pregnancy  occur,  all  the  changes  above  described  take 
place,  but,  inasmuch  as  the  ovary  partakes  of  the  stimulus  to  which 
all  the  generative  organs  are  then  subjected,  they  are  much  more 
marked  and  apparent.  Instead  of  contracting  and  disappearing  in  a 
few  weeks,  the  corpus  luteum  continues  to  grow  until  the  third  or 
fourth  month  of  pregnancy ;  the  folds  of  the  inner  layer  of  the  ovisac 
become  large  and  fleshy,  and  permeated  by  numerous  capillaries,  and 
ultim.ately  become  so  firmly  united  that  the  margins  of  the  convolu- 
tions thin  and  disappear,  leaving  only  a  firm  fleshy  yellow  mass, 
averaging  from  1  to  1^  inches  in  thickness,  which  surrounds  a  central 
cavity,  often  containing  a  whitish  fibrillated  structure,  believed  to 
be  the  remains  of  a  central  blood  clot.     This  was  erroneously  sup- 


FiG.  39. 


Fig.  40. 


Corpus  luteum  at  the  fourth  monfli  of  pregnancy. 
(After  Dalton.) 


Corpus  luteum  of  pregnaucy  at 
term.     (After  Dalton.) 


posed  by  Montgomery  to  be  the  inner  layer  of  the  follicle  itself,  and 
he  conceived  the  yellow  substance  to  be  a  new  formation  between  it 
and  the  external  layer,  while  Eobert  Lee  thought  it  was  placed  ex- 
ternal to  both  the  external  and  internal  layers. 


'  Arcliiv  de  Phys.  March,  1874. 


OVULATION    AND    MENSTRUATION.  77 

Between  the  third  and  fourth  months  of  pregnancy,  when  the 
corpus  luteum  has  attained  its  maximum  of  development  (Fig.  39), 
it  forms  a  firm  projection  on  the  surface  of  the  ovary,  averaging 
about  1  inch  in  length,  and  rather  more  than  J  an  inch  in  breadth. 
After  this  it  commences  to  atrophy  (Fig.  -iOj,  the  fiit-cells  become 
absorbed,  and  the  capillaries  disappear.  Cicatrization  is  not  com- 
plete until  from  one  to  two  months  after  delivery. 

Its  Value  as  a  Sign  of  Preynancy. — On  account  of  tlie  marked 
appearance  of  the  corpus  luteum  it  was  formerly  considered  to  be  an 
infallible  sign  of  pregnancy ;  and  it  was  distinguished  from  the  cor- 
pus luteum  of  the  non-pregnant  state  by  being  called  a  "  true"  as 
opposed  to  a  "  false"  corpus  luteum.  From  what  has  been  said  it 
will  be  obvious  that  this  designation  is  essentially  wrong,  as  the 
difference  is  one  of  degree  only.  Dalton^  applies  the  term  "false 
corpus  luteum"  to  a  degenerated  condition  sometimes  met  with  in  an 
unruptured  Graafian  follicle  consisting  in  re-absorption  of  its  contents, 
and  thickening  of  its  Avails.  It  differs  from  the  "true"  corpus 
luteum  in  being  deeply  seated  in  the  substance  of  the  ovary,  in 
having  no  central  clot,  and  in  being  unconnected  with  a  cicatrix  on 
the  surface  of  the  ovary.  Nor  do  obstetricians  attach  by  any  means 
the  same  importance  as  they  did  formerly  to  presence  of  this  corpus 
luteum  as  indicating  impregnation;  for  even  when  well  marked, 
other  and  more  reliable  signs  of  recent  delivery,  such  as  enlargement 
of  the  uterus,  are  sure  to  be  present,  especially  at  the  time  when  it 
has  reached  its  maximum  of  development ;  Avhile  after  delivery  at 
terra  it  has  no  longer  a  sufficiently  characteristic  appearance  to  be 
depended  on. 

Menstruation. — By  the  term  menstruation  (catamenia,  periods,  etc.), 
is  meant  the  periodical  discharge  of  blood  from  the  uterus,  which 
occurs,  in  the  healthy  woman,  every  lunar  month,  except  during 
pregnancy  and  lactation,  wdien  it  is,  as  a  rule,  suspended. 

Period  of  Estahlishinent. — ^The  first  appearance  of  menstruation  coin- 
cides with  the  establishment  of  puberty,  and  the  physical  changes 
that  accompany  it  indicate  that  the  female  is  capable  of  conception 
and  childbearing,  although  exceptional  cases  are  recorded  in  which 
pregnancy  occurred  before  menstruation  had  begun.  In  temperate 
climates  it  generally  commences  between  the  l-ith  and  16th  years, 
the  largest  number  of  cases  being  met  with  in  the  loth  year.  This 
rule  is  subject  to  many  exceptions,  it  being  by  no  means  very  rare 
for  menstruation  to  become  estabhshed  as  early  as  the  10th  or  11th 
years,  or  to  be  delayed  until  the  18th  or  20th.  Beyond  these  physio- 
logical limits  a  few  cases  are  from  time  to  time  met  with  in  which  it 
has  begun  in  early  infancy,  or  not  until  a  comparatively  late  period 
of  life. 

Influence  of  Cliraate^  Race,  etc. — Various  accidental  circumstances 
have  ranch  to  do  with  its  establishment.  As  a  rule,  it  occurs  some- 
what earlier  in  tropical,  and  later  in  very  cold,  than  in  temperate 
climates.     The  influence  of  climate  has  been  unduly  exaggerated.    It 

>  Op.  cit.,  p.  75. 


78  ORGANS    CONCERNED    IN    PARTURITION. 

used  to  be  generally  stated  that  in  the  Arctic  regions  women  did  not 
menstruate  until  they  were  of  mature  age,  and  that  in  the  tropics 
girls  of  10  or  12  years  of  age  did  so  habitually.  The  researches  of 
Eoberton,  of  Manchester/  first  showed  that  the  generally  received 
opinions  were  erroneous ;  and  the  collection  of  a  large  number  of 
statistics  has  corroborated  his  opinion.  There  can  be  no  doubt,  how- 
ever,  that  a  larger  proportion  of  girls  menstruate  early  in  warm  cli- 
mates.  Joulin  found  that  in  tropical  climates,  out  of  1635  cases,  the 
largest  proportion  began  to  menstruate  betw^een  the  12th  and  13th 
years;  so  that  there  is  an  average  difference  of  more  than  two  years 
between  the  period  of  its  establishment  in  the  tropics  and  in  tempe- 
rate countries.  Harris^  states  that  among  the  Hindoos  1  to  2  per  cent, 
menstruate  as  early  as  nine  years  of  age  ;  3  to  4  per  cent,  at  ten ;  8 
per  cent,  at  eleven ;  and  25  per  cent,  at  twelve ;  while  in  London  or 
Paris  probably  not  more  than  one  girl  in  1000  or  1200  does  so  at 
nine  years.  The  converse  holds  true  with  regard  to  cold  climates, 
although  we  are  not  in  possession  of  a  sufficient  number  of  accurate 
statistics  to  draw  very  reliable  conclusions  on  this  point ;  but  out  of 
4715  cases,  including  returns  from  Denmark,  Norway  and  Sweden 
Eussia  and  Labrador,  it  was  found  that  menstruation  was  established 
on  an  average  a  year  later  than  in  more  temperate  countries.  It  is 
probable  that  the  mere  influence  of  temperature  has  much  to  do  in 
producing  these  differences,  but  there  are  other  factors,  the  action  of 
which  must  not  be  overlooked.  Kaciborski  attributes  considerable 
importance  to  the  effect  of  race ;  and  he  has  quoted  Dr.  Webb,  of 
Calcutta,  to  the  effect  that  English  girls  in  Lidia,  although  subjected 
to  the  same  climatic  influence  as  the  Indian  races,  do  not,  as  a  rule, 
menstruate  earlier  than  in  England ;  while  in  Austria,  girls  of  the 
Magyar  race  menstruate  considerably  later  than  those  of  German  pa- 
rentage.^ The  surroundings  of  girls,  and  their  manner  of  education 
and  living,  have  probably  also  a  marked  influence  in  promoting  or 
retarding  its  establishment.  Thus,  it  wdll  commence  earlier  in  the 
children  of  the  rich,  who  are  likely  to  have  a  highly  developed  ner- 
vous organization,  and  are  habituated  to  luxurious  living,  and  a  pre- 
mature stimulation  of  the  mental  faculties  by  novel-reading,  society, 
and  the  like  ;  while  amongst  the  hard-worked  poor,  or  in  girls  brought 
up  in  the  country,  it  is  more  likely  to  begin  later.  Premature  sexual 
excitement  is  said  also  to  favor  its  early  appearance,  and  the  influ- 
ence of  this  among  the  factory  girls  of  Manchester,  who  are  exposed 
in  the  course  of  their  work,  to  the  temptations  arising  from  the  pro- 
miscuous mixing  of  the  sexes,  has  been  pointed  out  by  Dr.  Clay.* 

Changes  OccMrring  at  Puherty. — The  first  appearance  of  menstrua- 
tion is  accompanied  by  certain  well-marked  changes  in  the  female 
system,  on  the  occurrence  of  which  w^e  say  that  the  girl  has  arrived 
at  the  period  of  puberty.  The  pubes  become  covered  with  hair,  the 
breasts  enlarge,  the  pelvis  assumes  its  fully  developed  form,  and  the 

'  Edin.  Med.  and  Surg.  Journ.,  1832. 

2  Amer.  .Journ.  of  Obst.  1871.     R.  P.  Harris,  on  early  puberty.  , 

3  Op.  cit.,  p.  227. 

4  Brit.  Record  of  Obst.  Med.  vol.  i. 


OVULATrOX    AND    MENSTRUT A  ION  .  79 

general  contour  of  the  body  fills  out.  The  mental  qualities  also  alter; 
the  girl  becomes  more  shy  and  retiring,  and  her  whole  bearing  indi- 
cates the  change  that  has  taken  place.  The  menstrual  discharge  is 
not  established  regularly  at  once.  For  one  or  two  months  there  may 
be  only  premonitory  symptoms:  a  vague  sense  of  discomfort,  pains 
in  the  breasts,  and  a  feeling  of  weight  and  heat  in  the  back  and  loins. 
There  then  may  be  a  discharge  of  mucus  tinged  with  blood,  or  of 
pure  blood,  and  this  may  not  again  show  itself  for  several  months. 
Such  irregularities  are  of  little  consequence  on  the  first  establishment 
of  the  function,  and  need  give  rise  to  no  apprehension. 

Period  of  Duration  and  Recurrence. — As  a  rule,  the  discharge  re- 
curs every  twenty-eiglit  days,  and  with  some  women  with  such  regu- 
larity that  they  can  foretell  its  appearance  almost  to  the  hour.  The 
rule  is,  however,  subject  to  very  great  variations.  It  is  by  no  means 
uncommon,  and  strictly  within  the  limits  of  health,  for  it  to  appear 
every  twentieth  day,  or  even  with  less  interval ;  while  in  other  cases, 
as  much  as  six  weeks  may  habitually  intervene  between  two  periods. 
The  period  of  recurrence  may  also  vary  in  the  same  subject.  I  am 
acquainted  with  patients  who  sometimes  have  only  twenty-eight  days, 
at  others  as  many  as  forty-eight  days,  between  their  periods,  without 
their  health  in  any  way  suffering,  joulin  mentions  the  case  of  a  lady 
who  only  menstruated  two  or  three  times  in  the  year,  and  whose 
sister  had  the  same  peculiarity. 

The  duration  of  the  23eriod  varies  in  different  women,  and  in  the 
same  Avoman  at  different  times.  In  this  country  its  average  is  four 
or  five  days,  while  in  France,  Dubois  and  Bricrre  de  Boismont  fix 
eight  days  as  the  most  usual  length.  Some  women  are  only  unwell 
for  a  few  hours,  while  in  others  the  period  may  last  many  days  be- 
yond the  avei'age  without  being  considered  abnormal. 

Quantity  of  Blood  lost. — The  quantity  of  blood  lost  varies  in  dif- 
ferent Avomen.  Hippocrates  puts  it  at  oxviij,  which,  however,  is 
much  too  high  an  estimate.  Arthur  Farre  thinks  that  from  iij  to 
.5iij  is  the  full  amount  of  a  healthy  period,  and  that  the  quantity 
cannot  habitually  exceed  this  without  producing  serious  constitu- 
tional effects.  Bich  diet,  luxurious  living,  and  anything  that  un- 
healthily stimulates  the  body  and  mind,  will  have  an  injurious  effect 
in  increasing  the  flow,  which  is,  therefore,  less  in  hard-worked 
countrywomen  than  in  the  better  classes  and  residents  in  towns. 

It  is  more  abundant  in  warm  climates,  and  our  countrywomen  in 
India  habitually  menstruate  over-profusely,  becoming  less  abundantly 
unwell  when  they  return  to  England  ;  the  same  observation  has  been 
made  with  regard  to  American  women  residing  in  the  Gulf  States, 
who  improve  materially  by  removing  to  the  Lake  States.  Some 
women  appear  to  menstruate  more  in  summer  than  in  winter.  I  am 
acquainted  v/ith  a  lady  who  spends  the  winter  in  St.  Petersburgh, 
where  her  periods  last  eight  or  ten  days,  and  the  summer  in  Eng- 
land, where  they  never  exceed  four  or  five.  The  difference  is  prob- 
ably due  to  the  effect  of  the  over-heated  rooms  in  which  she  lives 
in  Bussia.  [I  have  known  insanity  to  result  from  the  exhaustion 
produced  by  this  excessive  menstrual  loss  in  the  far  south.     One 


80  ORGANS    CONCERNED    IN    PARTURITION. 

Louisiana  lady  came  in  tliis  condition  on  tliree  occasions  to  Pliiladel- 
pliia  for  treatment,  being  cured  upon  each  occasion.  After  the  third 
recovery,  she  accepted  the  advice  given  her  to  remain  north,  and  by 
so  doing  has  been  perfectly  well  for  several  years.  Two  young  ladies 
under  my  care,  born  in  this  city,  have  on  several  occasions  resided 
in  Florida ;  they  were  always  in  poor  health  from  menstrual  excess 
while  there,  but  had  the  function  restored,  to  its  normal  character 
after  their  return  to  a  cool  climate.  A  winter's  checking  influence 
has  often  a  marvellous  effect  in  cases  of  southern  patients,  made  thin 
and  miserable  by  this  oft-repeated  and  long-continued  drain. — Ed.] 

The  daily  loss  is  not  the  same  during  the  continuance  of  the  period. 
It  generally  is  at  first  slight,  and  gradually  increases  so  as  to  be  most 
profuse  on  the  second  or  third  day,  and  as  gradually  diminishes.  To- 
wards the  last  days  it  sometimes  disappears  for  a  few  hours,  and 
then  comes  on  again,  and  is  apt  to  recur  under  any  excitement  or 
emotion. 

Quality  of  Menstrual  Blood. — As  the  menstrual  fluid  escapes  from 
the  uterus  it  consists  of  pure  blood,  and,  if  collected  through  the 
speculum,  it  coagulates.  The  oj'dinary  menstrual  fluid  does  not 
coagulate  unless  it  is  excessive  in  amount.  Various  explanations  of 
this  fact  have  been  given.  It  was  formerly  supposed  either  to  contain 
no  fibrine,  or  an  unusually  small  amount.  Retzius  attributes  its 
non-coagulation  to  the  presence  of  free  lactic  and  phosphoric  acids. 
The  true  explanation  was  first  given  by  Mandl,  who  proved  that 
even  small  quantities  of  pus  or  mucus  in  blood  were  sufficient  to 
keep  the  fibrine  in  solution  ;  and  mucus  is  always  present  to  greater 
or  less  amount  in  the  secretions  of  the  cervix  and  vagina,  which  mix 
with  the  menstrual  blood  in  its  passage  through  the  genital  tract. 
If  the  amount  of  blood  be  excessive,  however,  the  mucus  present  is 
insufficient  in  quantity  to  produce  this  effect,  and  coagula  are  then 
formed. 

On  microscopic  examination  the  menstrual  fluid  exhibits  blood 
corpuscles,  mucous  corpuscles,  and  a  considerable  amount  of  epithelial 
scales,  the  last  being  the  debris  of  the  epithelium  lining  the  uterine 
cavity.  According  to  Virchow  the  form  of  the  epithelium  often 
proves  that  it  comes  from  the  interior  of  the  utricular  glands.  The 
color  of  the  blood  is  at  first  dark,  and  as  the  period  progresses  it 
generally  becomes  lighter  in  tint.  In  women  who  are  in  bad  health 
it  is  often  very  pale.  These  differences  doubtless  depend  upon  the 
amount  of  mucus  mingled  with  it.  The  menstrual  blood  has  always 
a  characteristic,  faint,  and  heavy  odor,  which  is  analogous  to  that 
which  is  so  distinct  in  the  lower  animals  during  the  rut.  Raciborski 
mentions  a  lady  who  was  so  sensitive  to  this  odor  that  she  could 
always  tell  to  a  certainty  when  any  woman  was  menstruating.  It 
is  attributed  either  to  decomposing  mucus  mixed  with  the  blood, 
which,  when  partially  absorbed,  may  cause  the  peculiar  odor  of  the 
breath  often  perceptible  in  menstruating  women;  or  to  the  mixture 
with  the  fluid  of  the  sebaceous  secretion  from  the  glands  of  the  vulva. 
It  probably  gave  rise  to  the  old  and  prevalent  prejudices  as  to  the 


OVULATION  AND  MENSTRUATION.  81 

deleterious  properties  of  menstrual  blood,  wliich,  it  is  needless  to  say, 
are  altogether  without  foundation. 

Source  of  the  Blood. — It  is  now  universally  admitted  that  the  source 
of  the  menstrual  blood  is  the  mucous  membrane  lining  the  interior 
of  the  uterus,  for  the  blood  may  be  seen  oozing  through  the  os  uteri 
by  means  of  the  speculum,  and  in  cases  of  prolapsus  uteri;  while  in 
cases  of  inverted  uterus  it  may  be  actually  observed  escaping  from 
the  exposed  mucous  membrane,  and  collecting  in  minute  drops  upon 
its  surface.  During  the  menstrual  nisus  the  whole  mucous  lining 
becomes  congested  to  such  an  extent  that,  in  examining  the  bodies 
of  women  who  have  died  during  menstruation,  it  is  found  to  be 
thicker,  larger,  and  thrown  into  folds,  so  as  to  completely  fill  the 
uterine  cavity.  The  capillary  circulation  at  this  time  becomes  very 
marked,  and  the  mucous  membrane  assumes  a  deep  red  hue,  the  net- 
work of  capillaries  surrounding  the  orifices  of  the  utricular  glands 
being  especially  distinct.  These  facts  have  an  unquestionable  con- 
nection with  the  production  of  the  discharge,  but  there  is  much  dif- 
ference of  opinion  as  to  the  precise  mode  in  which  the  blood  escapes 
from  the  vessels.  Coste  believed  that  the  blood  transudes  through 
the  coats  of  the  capillaries  without  any  laceration  of  their  structure. 
Farre  inclines  to  the  hypothesis  that  the  uterine  capillaries  terminate 
by  open  mouths,  the  escape  of  blood  through  these,  between  the 
menstrual  periods,  being  prevented  by  muscular  contraction  of  the 
uterine  walls.  Pouchet  believed  that  during  each  menstrual  ej^och 
the  entire  mucous  membrane  is  broken  down  and  cast  oft"  in  the  form 
of  minute  shreds,  a  fresh  mucous  membrane  being  developed  in  the 
interval  between  two  periods.  During  this  process  the  capillary 
network  would  be  laid  bare  and  ruptured,  and  the  escape  of  blood 
readily  accounted  for.  Tyler  Smith,  who  adopted  this  theory,  states 
that  he  has  frequently  seen  the  uterine  mucous  membrane,  in  w^omen 
wdio  have  died  during  menstruation,  in  a  state  of  dissolution,  with 
the  broken  loops  of  the  capillaries  exposed.  The  phenomena  at- 
tending the  so-called  membranous  dj-smenorrhoea,  in  which  the 
mucous  membrane  is  thrown  off  in  shreds,  or  as  a  cast  of  the  iiterine 
cavity — the  nature  of  which  w^as  first  pointed  out  by  Simpson  and 
Oldham — -have  been  supposed  to  corroborate  this  theory.  This  view 
is,  in  the  main,  corroborated  by  the  recent  researches  of  Engelman,^ 
Williams,^  and  others.  Williams  describes  the  mucous  lining  of  the 
uterus  as  undergoing  a  fatty  degeneration  before  each  period,  which, 
commences  near  the  inner  os,  and  extends  over  the  whole  mucous 
membrane,  and  down  to  the  muscular  wall.  This  seems  to  bring  on 
a  certain  amount  of  muscular  contraction,  which  drives  the  blood 
into  the  capillaries  of  the  mucosa,  and  these,  having  become  degene- 
rated, readily  rupture,  and  permit  the  escape  of  the  blood.  The 
mucous  membrane  now  rapidly  disintegrates,  and  is  cast  off  in  shreds 
with  the  menstrual  discharge,  in  Avhich  masses  of  epithelial  cells  may 
always  be  detected.     Engelman,  however,  holds  that  the  fatty  de- 

1  American  Journal  of  Obstetrics,  May,  1875. 

^  On  the  Structure  of  the  Mucous  Membrane  of  the  Uterus,  Obst.  Journ.,  1875. 


82  ORGANS    CONCERNED    IN    PARTURITION. 

generation  is  limited  to  the  superficial  layers,  and  that  a  portion  only 
of  the  epithelial  investment  is  thrown  ott'.  As  soon  as  the  period  is 
over  the  formation  of  a  new  mucous  membrane  is  begun,  from  pro- 
liferation of  the  elements  of  the  muscular  coat,  and  at  the  end  of  a 
week  the  whole  uterine  cavity  is  lined  by  a  thin  mucous  membrane. 
This  grows  until  the  advent  of  another  period,  when  the  same  de- 
generative changes  occur  unless  impregnation  has  taken  place,  in 
which  case  it  becomes  further  developed  into  the  decidua. 

Theory  of  Menstruation. — -That  there  is  an  intimate  connection  be- 
tween ovulation  and  menstruation  is  admitted  by  most  physiologists, 
and  it  is  held  by  many  that  the  determining  cause  of  the  discharge 
is  the  periodic  maturation  of  the  Graafian  follicles.  There  is  abundant 
evidence  of  this  connection,  for  we  know  that  when,  at  the  change 
of  life,  the  Graafian  follicles  cease  to  develop,  menstruation  is  arrested; 
and  wdien  the  ovaries  are  removed  by  operation,  of  which  there  are 
now  numerous  cases  on  record,  or  when  they  are  congenitally  absent, 
menstruation  does  not  generally  take  place.  A  few  cases,  however, 
have  been  observed  in  which  menstruation  continued  after  double 
ovariotomy,  and  these  have  been  used  as  an  argument  by  those 
physiologists  who  doubt  the  ovular  theory  of  menstruation.  Slav- 
yansky  has  particularly  insisted  on  such  cases,  which,  however,  are 
probably  susceptible  of  explanation.  It  may  be  that  the  habit  of 
menstruation  may  continue  for  a  time  even  after  the  removal  of  the 
ovaries,  and  it  has  not  been  shown  that  menstruation  has  continued 
permanently  after  double  ovariotomy,  although  it  certainly  has  occa- 
sionally, although  quite  exceptionally,  done  so  for  a  time.  It  is 
possible,  also,  that,  in  such  cases,  a  small  portion  of  ovarian  tissue 
may  have  been  left  unremoved,  sufficient  to  carry  on  ovulation. 
Roberts,  a  traveller  quoted  by  Depaul  and  Gueniot  in  their  article 
on  Menstruation  in  the  "  Dictionnaire  des  Sciences  Medicales,"  relates 
that  in  certain  parts  of  Central  Asia  it  is  the  custom  to  remove  both 
ovaries  in  young  girls  who  act  as  guards  to  the  harems.  These  women, 
known  as  hedjeras^  subsequently  assume  much  of  the  virile  type,  and 
never  menstruate.  The  same  close  connection  between  ovulation 
and  the  rut  of  animals  is  observed,  and  supports  the  conclusion  that 
the  rut  and  menstruation  are  analogous.  The  chief  difference  be- 
tween ovulation  in  man  and  the  lower  animals  is  that  in  the  latter 
the  process  is  not  generally  accompanied  by  a  sanguineous  flow.  To 
this  there  are  exceptions,  for  in  monkeys  there  is  certainly  a  discharge 
analogous  to  menstruation  occurring  at  intervals.  Another  point  of 
distinction  is  that  in  animals  connection  never  takes  place  except 
during  the  rut,  and  that  it  is  then  only  that  the  female  is  capable  of 
conception;  while  in  the  human  race  conception  only  occurs  in  the 
interval  between  the  periods.  This  is  another  argument  brought 
against  the  ovular  theory,  because,  it  is  said,  if  menstruation  depend 
on  the  rupture  of  a  Graafian  follicle  and  the  emission  of  an  ovule, 
then  impregnation  should  only  take  place  during  or  immediately 
after  menstruation.  Coste  explains  this  by  supposing  that  it  is  the 
maturation  and  not  the  rupture  of  the  follicle  which  determines  the 
occurrence  of  menstruation;  and  that  the  follicle  may  remain  unrup- 


OVULATION  AND  MENSTRUATION.  83 

tared  for  a  considerable  time  after  it  is  mature,  tlic  escape  of  the 
ovule  being  subsequently  determined  by  some  accidental  cause,  such 
as  sexual  excitement.  However  this  may  be,  there  is  good  reason 
to  believe  that  the  susceptibility  to  conception  is  greater  during  the 
menstrual  epochs.  Raciborski  believes  that  in  the  largo  proportic^n 
of  cases  impregnation  occurs  in  the  first  half  of  the  menstrual  interval, 
or  in  the  few  days  immediately  j^receding  the  appearance  of  the  dis- 
charge. There  are,  however,  very  numerous  exceptions,  for  in 
Jewesses,  who  almost  invariably  live  apart  from  their  husljands  for 
eight  days  after  the  cessation  of  menstruation,  impregnation  must 
constantly  occur  at  some  other  period  of  the  interval,  and  it  is  certain 
that  they  are  not  less  prolific  than  other  people.  This  rule  with  them 
is  very  strictly  adhered  to,  as  will  be  seen  by  the  accompanying  in- 
teresting letter  from  a  medical  friend  who  is  a  well-known  member 
of  that  community,  and  which  I  have  permission  to  publish.^  This 
fact  is  of  itself  sufficient  to  disprove  the  theory  advanced  by  Dr. 
Avrard,^  that  impregnation  is  impossible  in  the  latter  half  of  the 
menstrual  interval.  This,  and  the  other  reasons  referred  to,  un- 
doubtedly throw  some  doubt  on  the  ovular  theory,  but  they  do  not 
seem  to  be  sufficient  to  justify  the  conclusion  that  menstruation  is  a 
physiological  process  altogether  independent  of  the  development  and 
maturation  of  the  Graafian  follicles.  All  that  they  can  be  fairly  held 
to  prove  is  that  the  escape  of  the  ovules  may  occur  independently  of 
menstruation,  but  the  weight  of  evidence  remains  strongly  in  favor 
of  the  theory  which  is  generally  received. 

'  10  Bernard  Street,  Russell  Square,  July  28,  1873. 
My  dear  Sir. 

1.  ''J'o  the  best  of  my  knowledge  and  belief,  the  law  wliicli  prohibits  sexual 
intercourse  amongst  Jews  for  seven  clear  days  after  the  cessation  of  menstruation,  is 
almost  universally  observed  ;  the  exceptions  not  being  sufficient  to  vitiate  statistics. 
The  law  has  perliaps  fewer  exceptions  on  the  Continent  —  especially  Russia  and 
Poland,  where  the  Jewish  population  is  very  great — than  in  England.  Even  here, 
however,  women  who  observe  no  other  ceremonial  law  observe  this,  and  cling  to  it 
after  everything  else  is  thrown  overboard.  There  are  doubtless  many  exceptions, 
especially  among  the  better  classes  in  England,  who  keep  only  three  days  after  the 
cessation  of  the  menses. 

2.  The  law  is — as  you  state — that  should  the  discharge  last  only  an  hour  or  so,  or 
should  there  be  only  one  gush  or  one  spot  on  the  linen,  the  five  days  during  which 
the  period  might  continue  are  observed  ;  to  which  must  be  superadded  tlie  seven  clear 
days  =  twelve  days  per  mensem  in  which  connection  is  disallowed.  Sliould  any  dis- 
charge be  seen  in  the  intermenstrual  period,  seven  days  would  have  to  be  kept,  but 
not  the  five,  for  such  irregular  discharge. 

3.  The  "  bath  of  purification,"  which  must  contain  at  least  eighty  gallons,  is  used 
on  the  last  night  of  the  seven  clear  days.  It  is  not  used  till  after  a  bath  for  cleansing 
purposes  ;  and,  from  the  night  when  such  "  purifying"  bath  is  used,  Jewish  women 
are  accustomed  to  calculate  the  commencement  of  pregnancy.  That  you  should  not 
have  heard  it  is  not  strange  ;  its  mention  would  be  considered  highly  indelicate. 

4.  Jewish  women  reckon  their  pregnancy  to  last  nine  calendar  or  ten  lunar  months, 
270  to  280  days.  There  are  no  special  data  on  which  to  reckon  an  average,  nor  do 
I  know  of  auy  books  on  the  subject,  except  some  Talmudic  authorities  which  I  will 
look  up  for  you  if  you  desire  it.  Pray  make  no  apologies  for  writing  to  me  ;  any 
information  I  possess  is  at  your  service. 

I  am,  dear  Sir,  yours  very  truly. 
Dr.  Playfair.  A.  Asher. 

P.  S.  The  Biblical  foundation  for  the  law  of  the  seven  clear  days  is  Leviticus  xv., 
verse  19  till  tlie  end  of  the  chapter — especially  verse  28. 
2  Rev.  de  Therap.  Med.  Chir.,  1867. 


81  ORGANS    CONCERNED    IN    PARTURITION. 

Purpose  of  the  Menstrual  Loss. — The  cause  of  the  monthly  perio- 
dicity is  quite  unknown,  and  will  probably  always  remain  so. 
Goodman^  has  suggested  what  he  calls  the  "  cycical  theory  of  men- 
struation, "whicli  refers  the  phenomena  to  a  general  condition  of  the 
vascular  system,  specially  localizing  itself  in  the  generative  organs, 
and  connected  with  rhythmical  changes  in  their  nerve  centres.  It 
does  not  seem  to  me,  however,  that  he  has  satisfactorily  proved  the  re- 
currence of  the  conditions  which  his  ingenious  theory  assumes.  The 
purpose  of  the  loss  of  so  much  blood  is  also  somewhat  obscure.  To 
a  certain  extent  it  must  be  considered  an  accident  or  complication 
of  ovulation,  produced  by  the  vascular  turgescence.  Nor  is  it  essen- 
tial to  fecundation,  because  women  often  conceive  during  lactation, 
when  menstruation  is  suspended  ;  or  before  the  function  has  become 
established.  It  may,  however,  serve  the  negative  purpose  of  relieving 
the  congested  uterine  capillaries  which  are  periodically  filled  with  a 
supply  of  blood  for  the  great  growth  which  takes  place  when  concep- 
tion has  occurred.  Thus  immediately  before  each  period  the  uterus 
may  be  considered  to  be  placed  by  the  afflux  of  blood  in  a  state  of 
preparation  for  the  function  it  may  be  suddenly  called  upon  to  per- 
form. That  the  discharge  relieves  a  state  of  vascular  tension  which 
accompanies  ovulation  is  proved  by  the  singular  phenomenon  of 
vicarious  menstruation,  which  is  occasionally,  though  rarely,  met 
with.  It  occurs  in  cases  in  Avhich,  from  some  unexplained  cause, 
the  discharge  does  not  escape  from  the  uterine  mucous  membrane. 
Under  such  circumstances  a  more  or  less  regular  escape  of  blood  may 
take  place  from  other  sites.  The  most  common  situations  are  the 
mucous  membranes  of  the  stomach,  of  the  nasal  cavities,  or  of  the 
lungs;  the  skin,  not  uncommonly  that  of  the  mammae,  probably  on 
account  of  their  intimate  sympathetic  relation  with  the  uterine 
organs;  from  the  surface  of  an  ulcer;  or  from  hemorrhoids.  It  is  a 
noteworthy  fact  that  in  all  these  cases  the  discharge  occurs  in  situa- 
tions where  its  external  escape  can  readily  take  place.  This  strange 
deviation  of  the  menstrual  discharge  may  be  taken  as  a  sign  of 
general  ill-health,  and  it  is  usually  met  with  in  delicate  j^oung  women 
of  highly  mobile  nervous  constitution.  It  may,  however,  begin  at 
puberty,  and  it  has  even  been  observed  during  the  whole  sexual  life. 
The  recurrence  is  regular,  and  always  in  connection  with  the  men- 
strual nisus,  although  the  amount  of  blood  lost  is  much  less  than  in 
ordinary  menstruation. 

Cessation  of  Menstruation. — After  a  certain  time  changes  occur, 
showing  that  the  woman  is  no  longer  fitted  for  reproduction ;  men- 
struation ceases.  Graafian  follicles  are  no  longer  matured,  and  the 
ovary  becomes  shrivelled  and  wrinkled  on  its  surface.  Analogous 
alterations  take  place  in  the  uterus  and  its  appendages.  The  Fallo- 
pian tubes  atroph}',  and  are  not  unfrequently  obliterated.  The  uterus 
decreases  in  size.  The  cervix  undergoes  a  remarkable  change  which 
is  readily  detected  on  vaginal  examination.  The  projection  of  the 
cervix  into  the  vaginal  canal  disappears,  and  the  orifice  of  the  os 

'  Amei'ican  Journal  of  Obstetrics,  Oct.  1878. 


OVULATION    AND    MENSTRUATION.  85 

uteri  in  old  women  is  found  to  be  flusli  with  tlie  roof  of  the  vagina. 
In  a  large  number  of  cases  there  is  after  the  cessation  of  menstrua- 
tion, an  occlasion  both  of  the  external  and  internal  os;  the  canal  of 
the  cervix,  however,  between  them  remains  patulous,  and  is  not  un- 
frequently  distended  with  a  mucous  secretion. 

Period  of  Cessation. — The  age  at  which  menstruation  ceases  varies 
much  in  different  women.  In  certain  cases  it  may  cease  at  an  unusu- 
ally early  age,  as  between  30  and  40  years,  or  it  may  continue  far 
beyond  the  average  time,  even  up  to  60  years ;  and  exceptional, 
though  perhaps  hardly  reliable  instances,  are  recorded  in  which  it 
has  continued  even  to  80  or  90  years.  These,  are,  however,  strange 
anomalies,  which,  like  cases  of  unusually  precocious  menstruation, 
cannot  be  considered  as  having  any  bearing  on  the  general  rule. 
Most  cases  of  so-called  protracted  menstruation  will  be  found  to  be 
really  morbid  losses  of  blood  de])ending  on  malignant  or  other  forms 
of  organic  disease,  the  existence  of  which,  under  such  circumstances, 
should  always  be  suspected. 

In  this  country  menstruation  usually  ceases  between  40  and  50 
years  of  age.  Eaciborski  says  that  the  largest  number  of  cases  of 
cessation  are  met  with  in  the  46th  year.  It  is  generally  said  that 
women  who  commence  to  menstruate  when  very  young,  cease  to  do 
so  at  a  comparatively  early  age,  so  that  the  average  duration  of  the 
function  is  about  the  same  in  all  women.  Cazeaux  and  Eaciborski, 
Avhose  opinion  is  strengthened  by  the  observations  of  Guy  in  1500 
cases,^  think,  on  the  contrary,  that  the  earlier  menstruation  com- 
mences, the  longer  it  lasts,  early  menstruation  indicating  an  excess 
of  vital  energy  which  continues  during  the  Av^hole  child-bearing  life. 
Climate  and  other  accidental  causes,^  do  not  seem  to  have  as  much 
effect  on  the  cessation  as  on  the  establishment  of  the  function.  It 
does  not  appear  to  cease  earlier  in  warm  than  in  temperate  climates. 
The  change  of  life  is  generally  indicated  by  irregularities  in  the 
recurrence  of  the  discharge.  It  seldom  ceases  suddenly,  but  it  may 
be  absent  for  one  or  more  periods,  and  then  occur  irregularly ;  or  it 
may  become  profuse  or  scanty,  until  eventually  it  entirely  stops. 
The  popular  notions  as  to  the  extreme  danger  of  the  menopause  are 
probably  much  exaggerated ;  although  it  is  certain  that  at  that  time 
various  nervous  phenomena  are  apt  to  be  developed.  So  far  from 
having  a  prejudicial  effect  on  the  health,  however,  it  is  not  an  un- 
common observation  to  see  an  hysterical  woman,  who  has  been  for 
years  a  martyr  to  uterine  and  other  complaints,  apparently  take  a 
new  lease  of  life  when  her  uterine  functions  have  ceased  to  be  in 
active  operation,  and  statistical  tables  abundantly  prove  that  the 
general  mortality  of  the  sex  is  not  greater  at  this  than  at  any  other 
time. 

»  Med.  Times  and  Gaz.,  1845. 


PAET    II. 

PREGNANCY. 


CHAPTER   I. 


cOiSrcEPTioisr  and  generation. 

Generation  in  the  human  female,  as  in  all  mammals,  requires  the 
congress  of  the  two  sexes,  in  order  that  the  semen,  the  male  element 
of  generation,  may  be  brought  into  contact  with  the  ovule,  the  female 
element  of  generation. 

Semen. — The  semen  secreted  by  the  testicle  of  an  adult  male  is  a 
viscid,  opalescent  fluid,  forming  an  emulsion  when  mixed  with 
water,  and  having  a  peculiar  faint  odor,  which  is  attributed  to  the 
secretions  which  are  mixed  with  it,  such  as  those  from  the  prostate 
and  Cowper'c  glands.  On  analysis  it  is  found  to  be  an  albuminous 
fluid,  holding  in  solution  various  salts,  principally  phosphates  and 
chlorides,  and  an  animal  substance,  spermatine,  analogous  to  fibrine. 
Examined  under  a  magnifying  power  of  from  400  to  500  diameters, 
it  consists  of  a  transparent  and  homogeneous  fluid,  in  which  are  float- 
ing a  certain  number  of  granules  and  epithelial  cells,  derived  from 
the  secretions  mixed  Avith  it,  and  the   characteristic  sperm  cells  and 

spermatozoa  which  form  its  essen- 
Fig.  41.  tial  constituents  (Fig.  41).     The 

sperm  cells  are  large  spherical 
vesicles,  each  containing  from  two 
to  eight  smaller  cells,  within  which 
the  spermatozoa  are  developed  ; 
and,  as  these  soon  escape  and  be- 
come free,  the  sperm  cells  are 
only  to  be  detected  in  the  testicles 
themselves,  while  in  semen  that 
has  been  ejaculated  they  are  rarely 
visible.  The  large  parent  cell, 
termed  by  Robin  the  male  ovule, 
forms  within  it  several  subsidiary 
cells  by  the  segmentation  of  its 
granular  contents.  Within  these 
secondary  cells,  or  vesicles  of  evo- 
lution, which  are  believed  by  Kolliker  to  be  developed  from  the 
nuclei  of  the  parent  cell,  the  spermatozoa  are  formed,  and  before 
ejaculation  they  may  be  seen  coiled  spirally  in  their  interior.  The 
external  envelope  then  disappears,  and  a  number  of  spermatozoa,  one 
(86) 


a,  b.  Sperm  ceUs  containing'  nuclei,  each  nu- 
cleus having  within  a  spermatozoon,  c.  Nucleus, 
with  nucleoli.  d.  Nucleus,  with  spermato- 
zoon, e.  A  cell,  wi'h  a  bundle  of  spermatic 
filaments.   /,  g,  h.  Spermatozoa. 


CONCEPTION    AND    GENERATION.  87 

being  formed  in  each  of  the  secondary  cells,  may  be  observed  in  the 
interior  of  the  original  parent  cell.  Eventually  that  also  is  absorbed, 
and  the  contained  spermatozoa  become  liberated,  and  move  about 
freely  in  the  seminal  fluid.  As  fieen  under  the  microscope,  the  sper- 
matozoa, which  exist  in  healthy  semen  in  enormous  numbers,  present 
the  appearance  of  minute  particles,  not  unlike  a  tadpole  in  shape. 
The  head  is  oval  and  flattened,  measuring  about  sT^ajj  of  an  inch 
in  breadth,  and  attached  to  it  is  a  delicate  lilamentous  expansion  or 
tail,  which  tapers  to  a  point  so  fine  that  its  termination  cannot  be 
seen  by  the  highest  powers  of  the  microscope.  The  whole  sperma- 
tozoon measures  from  ^^  to  ^J^-^  of  an  inch  in  length.  The 
spermatozoa  are  observed  to  be  in  conste^nt  motion,  sometimes  very 
rapid,  sometimes  more  gentle,  which  is  supposed  to  be  the  means 
by  Avhich  they  pass  upwards  through  the  female  genital  organs. 
They  retain  their  vitality  and  power  of  movement  for  a  consider- 
able time  after  emission,  provided  the  semen  is  kept  at  a  temperature 
similar  to  that  of  the  body.  Under  such  circumstances  they  have 
been  observed  in  active  motion  from  forty-eight  to  seventy-two 
hours  after  ejaculation,  and  they  have  also  been  seen  alive  in  the  tes- 
ticle as  long  as  twenty-four  hours  after  death.  In  all  probability 
they  continue  active  much  longer  within  the  generative  organs,  as 
many  physiologists  have  observed  them  in  full  vitality  in  bitches 
and  rabbits,  seven  or  eight  days  after  copulation.  The  recent  ex- 
periments of  Haussman,  however,  shoAv  that  they  lose  their  power  of 
motion  in  the  human  vagina  within  twelve  hours  after  coitus,  although 
they  doubtless  retain  it  longer  in  the  uterus  and  Fallopian  tubes. 
Abundant  leucorrhoeal  discharges  and  acrid  vaginal  secretions  de- 
stroy their  movements,  and  may  thus  cause  sterility  in  the  female. 
On  account  of  their  mobility,  the  spermatozoa  were  long  considered 
to  be  independent  animalcules,  a  view  which  is  by  no  means  exploded, 
and  has  been  maintained  in  modern  times  by  Pouchet,  Joulin,  and 
other  writers,  while  Coste,  Robin,  Kcilliker,  etc.,  liken  their  motion 
to  that  of  ciliated  epithelium.  There  can  be  no  doubt  that  the  fer- 
tilizing power  of  the  semen  is  due  to  the  presence  of  the  spermatozoa, 
although  some  of  the  older  physiologists  assigned  it  to  the  spermatic 
fluid.  The  former  view,  however,  has  been  conclusively  proved  by 
the  experiments  of  Prevost  and  Dumas,  who  found  that  on  carefully 
removing  the  spermatozoa  by  filtration  the  semen  lost  its  fecundating 
properties. 

iSites  of  Impregnation. — There  has  been  great  difference  of  opinion 
as  to  the  part  of  the  genital  tract  in  which  the  spermatozoa  and  the 
ovule  come  into  contact,  and  in  which  impregnation,  therefore,  occurs. 
Spermatozoa  have  been  observed  in  all  parts  of  the  female  genital 
organs  in  animals  killed  shortly  after  coitus,  especially  in  the  Fallo- 
pian tubes,  and  even  on  the  surface  of  the  ovary.  The  phenomena  of 
ovarian  gestation,  and  the  fact  that  fecundation  has  been  proved  to 
occur  in  certain  animals  within  the  ovary,  tend  to  support  the  idea 
that  it  may  also  occur  in  the  human  female  before  the  rupture  of  the 
Graafian  follicle.  In  order  to  do  so,  however,  it  is  necessary  for  the 
spermatozoa  to  penetrate  the  proper  structure  of  the  follicle  and  the 


88 


PREGNANCY. 


epithelial  covering  of  the  ovary,  and  no  one  has  actually  seen  them 
doing  so.  Most  probably  the  contact  of  the  spermatozoa  and  the 
ovule  occurs  very  shortly  after  the  rupture  of  the  follicle,  and  in  the 
outer  part  of  the  Fallopian  tubes.  Coste  mentions  that,  unless  the 
ovule  is  impregnated,  it  ver}>  rapidly  degenerates  after  being  expelled 
from  the  ovary,  partly  by  inherent  changes  in  the  ovule  itself,  and 
partly  because  it  then  soon  becomes  invested  by  an  albuminous 
covering  which  is  impermeable  to  the  spermatozoa.  He  believes, 
therefore,  that  impregnation  can  only  occur  either  on  the  surface  of 
the  ovary,  or  just  within  the  fimbriated  extremity  of  the  tube. 

Mode  in  which  the  ascerit  of  the  Sem.en  is  effected.- — The  semen  is 
probably  carried  upwards  chiefly  by  the  inherent  mobility  of  the 
spermatozoa.  It  is  believed  by  some  that  this  is  assisted  by  other 
agencies;  amongst  them  are  mentioned  the  peristaltic  action  of  the 
uterus  and  Fallopian  tubes ;  a  sort  of  capillary  attraction  effected 
when  the  walls  of  the  uterus  are  in  close  contact,  similar  to  the  move- 
ment of  fluid  in  minute  tubes ;  and  also  the  vibratile  action  of  the  cilia 
of  the  epithelium  of  the  uterine  mucous  membrane.  The  action  of 
the  latter  is  extremely  doubtful,  for  they  are  also  supposed  to  effect 
the  descent  of  the  ovule,  and  they  can  hardly  act  in  two  opposite  ways. 
The  movement  of  the  cilia  being  from  within  outwards,  it  would  cer- 
tainly oppose,  rather  than  favor,  the  progress  of  the  spermatozoa. 
It  must,  therefore,  be  admitted  that  they  ascend  chiefly  through 
their  own  powers  of  motion.  They  certainly  have  this  power  to  a 
remarkable  extent,  for  there  are  numerous  cases  on  record  in  which 
impregnation  has  occurred  without  penetration,  and  even  when  the 
hymen  was  quite  entire,  and  in  Avhich  the  semen  has  simply  been  de- 
posited on  the  exterior  of  the  vulva;  in  such  cases,  which  are  far 
from  uncommon,  the  spermatozoa  must  have  found  their  way  through 
the  whole  length  of  the  vagina.  It  is  probable,  however,  that  under 
ordinary  circumstances  the  passage  of  the  spermatic  fluid  into  the 

uterus  is  facilitated  by  changes  which  take 
place  in  the  cervix  during  the  sexual  or- 
gasm, in  course  of  which  the  os  uteri  is 
said  to  dilate  and  close  again  in  a  rhythmi- 
cal manner.^ 

Mode    of    Impregnation. — The     precise 

method  in  which  the  spermatozoa  effect 

impregnation  was  long  a  matter  of  doubt. 

It   is    now,    however,    certain    that   they 

actually  penetrate  the  ovule,  and  reach  its 

interior.      This     has    been    conclusively 

proved    by    the    observations   of    Barry, 

Ovum  of  Rabbit  containing  sperma-    Mcissuer,  and  otlicrs,  who  havc  Seen  the 

*°^''^'  spermatozoa    within    the    external    mem- 

1.  zonapenncida    2.  The  germs     ferauc  of  the  ovulc  in  rabbits  (Fig.  42).    In 

consisting  of  two  largo  cells,  several  n     ^        •  ^  i 

smaller  cells,  and  spermatozoa.  somc  ot  the  invcrtebrata  a  cauai  or  opeii- 


FiG.  42 


'  How  do  the  Spermatozoa  enter  the  Uterus  ?  by  J.  Beck,  M.D. 


CONCEPTION    AND    GENERATION.  89 

ing  exists  in  the  zona  pellucida,  through  which  the  spermatozoa  pass. 
No  such  aperture  has  yet  been  demonstrated  in  the  ovules  of  mam- 
mals, but  its  existence  is  far  I'rom  improbable.  According  to  the 
observations  of  Newport,  several  spermatozoa  enter  the  ovule,  and 
the  greater  the  number  that  do  so  the  more  certain  fecundati(m  be- 
comes. After  the  spermatozoa  penetrate  the  zona  pellucida  they 
disintegrate  and  mingle  with  the  yelk,  having,  while  doing  so,  im- 
parted to  the  ovule  a  power  of  vitality,  and  initiated  its  development 
into  a  new  being. 

Progress  of  the  Impre'jnated  Ovule  towards  the  Uterus. — The  length 
of  time  which  lapses  before  the  fecundated  ovule  arrives  in  the  cav- 
ity of  the  uterus  has  not  yet  been  ascertained,  and  it  probably  varies 
under  different  circumstances.  It  is  known  that  in  the  bitch  it  may 
remain  eight  or  ten  days  in  the  Fallopian  tube,  in  the  guinea-pig 
three  or  four.  In  the  human  female  the  ovum  has  never  been  dis- 
covered in  the  cavity  of  the  uterus  before  the  tenth  or  twelth  day 
after  impregnation. 

Chanfjes  immediately  hefore  and  after  Impregnation. — The  changes 
which  occur  in  the  human  ovule  immediately  before  and  after  im- 
pregnation, and  during  its  progress  through  the  Fallopian  tube,  are 
only  known  to  us  by  analogy,  as,  of  course,  it  is  impossible  to  study 
them  by  actual  observation.  We  are  in  possession,  hoAvever,  of  ac- 
curate information  of  what  has  been  made  out  in  the  lower  animals, 
and  it  is  reasonable  to  suppose  that  similar  changes  occur  in  man. 
Immediately  after  the  ovule  has  passed  into  the  Fallopian  tube,  it  is 
found  to  be  surrounded  by  a  layer  of  granular  cells,  a  portion  of  the 
lining  membrane  of  the  Graafian  follicle,  which  was  described  as  the 
discus  proligerus.  As  it  proceeds  along  the  tube  these  surrounding 
cells  disappear,  partly,  it  is  supposed,  by  friction  on  the  walls  of  the 
tube,  and  partly  by  being  absorbed  to  nourish  the  ovule.  Be  this  as 
it  may,  before  long  they  are  no  longer  observed,  and  the  zona  pellu- 
cida forms  the  outermost  layer  of  the  ovule.  When  the  ovule  has 
advanced  some  distance  along  the  tube,  it  becomes  invested  with  a 
covering  of  albuminous  material,  which  is  deposited  around  it  in  suc- 
cessive layers,  the  thickness  of  which,  vanes  in  different  animals.  It 
is  very  abundant  in  birds,  in  whom  it  forms  the  familiar  white  of  the 
egg.  In  some  animals  it  has  not  been  detected,  so  that  its  presence 
in  the  human  ovule  is  uncertain.  Where  it  exists  it  doubtless  con- 
tributes to  the  nourishment  of  ^  the  ovule.  Coincident  with  these 
changes  is  the  disappearance  of  the  germinal  vesicle.  At  the  same 
time  the  yelk  contracts  and  becomes  more  solid ;  retiring,  in  one 
spot,  from  close  contact  with  the  zona  pellucida,  and  thus  forming  a 
species  of  cavity  called  by  Newport  the  respiratory  chamher^  which 
in  some  animals  is  filled  with  a  transparent  liquid.  After  this  occurs 
the  very  peculiar  phenomenon  known  as  the  cleavage  of  the  yelk, 
which  results  in  the  formation  of  the  membrane  from  which  the  foetus 
is  developed.  It  is  preceded  by  the  formation  at  one  point  of  the 
surface  of  the  yelk  of  a  minute  transparent  globule  of  a  bluish  tint, 
sometimes  of  three  or  four  separate  globules  which  subsequently  unite 
into  one.  This  has  received  the  name  of  \h.Q  polar  globule  (Fig.  43), 
7 


90 


PREGNANCY, 


and  seems  to  be  formed  from  the  hya-  Fig.  43. 

line  substance  of  the  yelk,  from  which 
it  soon  becomes  entirely  separated,  and 
remains  attached  to  the  inner  surface 
of  the  zona  pellucida.  It  indicates  the 
point  at  which  the  segmentation  of  the 
yelk  begins,  and  where  the  cephalic  ex- 
tremity of  the  foetus  will  subsequently 
be  placed. 

According  to  Robin  these  changes 
occur  in  all  ovules,  whether  they  are 
impregnated  or  not,  but  if  the  ovule  is 
not  fecundated,  no  further  alterations 
occur.  Supposing  impregnation  has 
taken  place,  a  bright  clear  vesicle,  called 
the  vitelline  nucleus^  very  similar  in 
appearance  to  a  drop  of  oil,  appears  in  the  centre  of  the  yelk.  The 
segmentation  of  the  yelk  (Fig.  44)  commences  at  the  point  where  the 
polar  globule  is  situated ;  it  begins  to  divide  into  two  halves,  and  at 


Formatioa  of  the  "Polar  Globule." 
1.  Zona  Pellucida,  sontainiug  sperma- 
tozoa.      2.  Yeil:.      3  and   4.    Gei-niinal 
Vesicle.    5.  The  Polar  Globule. 


Fig.  44. 


Segmentatioa  of  the  Yelk. 

A.  Ovum  with  first  Embryo  cell.     B.  Division  of  embryo  cell  and  cleavage  of  the  yelk  around  it. 
C,  D,  E.     Further  division  of  the  yelk. 

the  same  time  the  vitelline  nucleus  becomes  constricted  in  its  centre, 
and  separates  into  two  portions,  one  of  which  forms  a  centre  for  each 
of  the  halves  into  which  the  yelk  has  divided.  Each  of  these  im- 
mediately divides  into  two,  as  does  its  contained  portion  of  the  vitel- 
line nucleus,  and  so  on  in  rapid  succession  until  the  whole  yelk  is 
divided  into  a  number  of  spheres,  each  of  which  consists  of  a  clump 
of  nucleated  protoplasm. 

By  these  continuous  dichotomous  divisions  the  whole  yelk  is 
formed  into  a  granular  mass  which,  from  its  supposed  resemblance 
to  a  mulberry,  has  been  named  the  muriform  hody.  When  the  sub- 
division of  the  yelk  is  completed,  its  separate  spheres  become  con- 
verted  into   cells,   consisting   of  a   fine    membrane    with    granular 


CONCEPTION    AND    GENERATION.  01 

contents.  These  cells  unite  by  their  edges  to  form  a  continuous 
membrane  (Fig.  45),  which,  through  the  expansion  of  the  muriform 
body  by  fluid  which  forms  in  its  interior,  U  distended  until  it  forms 
a  lining  to  the  y.on'A,  pellucida.  This  is  the  blasiodermtc  membrane 
from  which  the  foatus  is  developed.  By  this  time  the  ovum  has 
reached  the  uterus,  and,  before  proceeding  to  consider  the  further 

Fi<:.  4;'. 


"^ 


\ 


%. 


Form-ition  of  the  Blastodermic  Membrane  from  the  colls  of  the  Blurlform  Body.      (After  JouUn.) 
1.  Layer  of  albuminous  material  surrounding  2.  The  Zona  pellucida. 

changes  which  it  undergoes  it  Avill  be  well  to  study  the  alteration 
which  the  stimulus  of  impregnation  has  set  on  foot  in  the  mucous 
membrane  of  the  uterus,  in  order  to  prepare  it  for  the  reception  and 
growth  of  its  contents. 

Changes  in  the  Uterine  Mucous  Membrane  consequent  on  Pregnancy. 
— Even  before  the  ovum  reaches  the  uterus,  the  mucous  membrane 
becomes  thickened  and  vascular,  so  that  its  opposing  surfaces  entirely 
fill  the  uterine  cavity.  These  changes  may  be  said  to  be  the  same 
in  kind,  although  more  marked  and  extensive  in  degree,  as  the  alter- 
ations which  take  place  in  the  mucous  membrane  in  connection 
with  each  menstrual  period.  The  result  is  the  formation  of  a  distinct 
membrane,  which  affords  the  ovum  a  safe  anchorage  and  protection, 
until  its  connections  with  the  uterus  are  more  fully  developed.  After 
delivery,  this  membrane,  which  is  by  that  time  quite  altered  in 
appearance,  is  at  least  partially  thrown  off  with  the  ovum  ;  on  which 
account  it  has  received  the  name  of  the  decidua^  or  caduca. 

Divisions  of  the  Decidua. — -The  decidua  consists  of  two  principal 
portions,  which,  in  early  pregnancy,  are  separated  from  each  other 
by  a  considerable  interspace.  One  of  these,  called  the  decidua  vera, 
lines  the  entire  uterine  cavity,  and  is,  no  doubt,  the  original  mucous 
lining  of  the  uterus  greatly  hypertrophied.  The  second,  the  decidua 
reflexa,  is  closely  applied  round  the  ovum  ;  and  it  is  probably  formed 
by  the  sprouting  of  the  decidua  vera  around  the  ovum  at  the  point 


92  PREGNANCY. 

on  wTiicli  the  latter  rests,  so  that  it  eventually  completely  surrounds 
it.  As  the  ovum  enlarges,  the  decidua  reiiexa  is  necessarily  stretched, 
until  it  comes  everywhere  into  contact  with  the  decidua  vera,  with 
which  it  firmly  unites.  After  the  third  month  of  pregnancy  true 
union  has  occurred,  and  the  two  layers  of  decidua  are  no  longer 
separate.  The  decidua  serotina,  which  is  descril3ed  as  a  third  portion, 
is  merely  that  part  of  the  decidua  vera  on  which  the  ovum  rests,  and 
where  the  placenta  is  eventually  developed. 

Views  of  William  and  John  Hunter. — It  is  needless  to  refer  to  the 
various  views  which  have  been  held  by  anatomists  as  to  the  struc- 
ture and  formation  of  the  decidua.  That  taught  by  John  Hunter 
was  long  believed  to  be  correct,  and  down  to  a  recent  date  it  received 
the  adherence  of  most  physiologists.  He  believed  the  decidua  to  be 
an  inflammatory  exudation  which,  on  account  of  the  stimulus  of 
pregnancy,  was  thrown  out  all  over  the  cavity  of  the  uterus,  and 
soon  formed  a  distinct  lining  membrane  to  it.  When  the  ovum 
reached  the  uterine  orifice  of  the  Fallopian  tube  it  found  its  entrance 
barred  by  this  new  membrane,  which  accordingly  it  pushed  before 
it.  This  separated  portion  formed  a  covering  to  the  ovum,  and 
became  the  decidua  reflexa ;  while  a  fresh  exudation  took  place  at 
that  portion  of  the  uterine  wall  which  was  thus  laid  bare,  and  this 
became  the  decidua  vera.  William  Hunter  had  much  more  correct 
views  of  the  decidua,  the  accuracy  of  which  was  at  the  time  much 
contested,  but  which  have  recently  received  full  recognition.  He 
describes  the  decidua  in  his  earlier  writings  as  an  hypertrophy  of 
the  uterine  mucous  membrane  itself,  a  view  which  is  now  held  by 
all  physiologists. 

Struchire  of  the  Decidua. — When  the  decidua  is  first  formed  it  is  a 
hollow  triangular  sac  lining  the  uterine  cavity  (Fig.  46),  and  having 
three  openings  into  it,  those  of  the  Fallopian  tubes  at  its  upper 
angles,  and  one,  corresponding  to  the  internal  os  uteri,  below.  If, 
as  is  generally  the  case,  it  is  thick  and  pulpy,  these  openings  are 
closed  up  and  can  no  longer  be  detected.  In  early  pregnancy  it  is 
well  developed,  and  continues  to  grow  up  to  the  third  month  of 
utero-gestation.  After  that  time  it  commences  to  atrophy,  its  adhe- 
sion with  the  uterine  walls  lessens,  it  becomes  thin  and  transparent, 
and  is  ready  for  expulsion  when  delivery  is  effected.  When  it  is 
most  developed,  a  careful  examination  of  the  decidua  enables  us  to 
detect  in  it  all  the  elements  of  the  uterine  mucous  membrane  greatly 
hypertrophied.  Its  substance  chiefly  consists  of  large  round  or  oval 
nucleated  cells  and  elongated  fibres,  mixed  with  the  tubular  uterine 
gland  ducts,  which  are  much  elongated  and  filled  with  cylindrical 
epithelium  cells,  and  a  small  quantity  of  milky  fluid.  According  to 
Friedlander  the  decidua  is  divisible  into  two  layers :  the  inner  being 
formed  by  a  proliferation  of  the  corpuscles  of  the  sub-epithelial  con- 
nective tissue  of  the  mucous  membrane ;  the  deeper,  in  contact  with 
the  uterine  walls,  out  of  flattened  or  compressed  gland  ducts.  In  an 
early  abortion  the  extremities  of  these  ducts  may  be  observed  by  a 
lens  on  the  external  or  uterine  surface  of  the  decidua,  occupying  the 
summit  of  minute  projections,  separated  from  each  other  by  depres- 


CONCEPTION    AND    GENERATION. 


93 


sions.  If  these  projections  be  bisected  tliey  will  be  found  to  contain 
little  cavities,  filled  with  lactescent  fluid,  which  were  first  described 
hy  Montgomery  of  Dublin,  and  are   known  as  Montfjomen/s  cups. 


Fig.  46. 


Aborted  Ovum  of  about  forty  days,  showing  the  Triangular  Shape  of  the  Decidua  (which  is  laid 
open),  and  the  Aperture  of  the  Fallopian  Tube.     (After  Coste.) 

Thej  are  in  fact  the  dilated  canals  of  the  uterine  tubular  glands. 
On  the  internal  surface  of  such  an  early  decidua  a  number  of  shallow 
depressions  may  be  made  out,  which  are  the  open  mouths  of  these 
ducts. 

Form,ation  of  the  Decidua  Reflexa. — When  the  ovum  reaches  the 
uterine  cavity  it  soon  becomes  imbedded  in  the  folds  of  the  hyper- 
trophied  mucous  membrane,  which  almost  entirely  fills  the  uterine 
cavity.  As  a  rule  it  is  attached  to  some  point  near  the  opening  of 
a  Fallopian  tube,  the  swollen  folds  of  mucous  membrane  preventing 
its  descent  to  the  lower  part  of  the  uterus;  in  exceptional  circum- 
stances, however,  as  in  women  who  have  borne  many  children,  and 
have  a  more  than  usually  dilated  uterine  cavity,  it  may  fix  itself  at 
a  point  much  nearer  the  internal  os  uteri.  According  to  the  now 
generally  accepted  opinion  of  Coste,  the  mucous  membrane  at  the 
base  of  the  ovum  soon  begins  to  sprout  around  it  and  gradually  ex- 
tends  until  it  eventually  completely  covers  the  ovum  (Figs.  47-49), 
and  forms  the  decidua  reflexa.  Coste  describes,  under  the  name  of 
the  umbilicus,  a  small  depression  at  the  most  prominent  part  of  the 
ovum,  which  he  considers  to  be  the  indication  of  the  point  where  the 
closure  of  the  decidua  reflexa  is  effected.  There  are  some  objections 
to  this  theory,  for  no  one  has  seen  the  decidua  reflexa  incomplete 
and  in  the  process  of  formation,  and  on  examining  its  internal  surface, 
that  is,  the  one  furthest  from  the  ovum,  its  microscopical  appearance 


94 


PREGNANCY. 


is  identical  witli  that  of  tlie  inner  surface  of  the  deci  lua  vera.  To 
meet  these  difficulties,  Weber  and  Goodsir,  whose  views  have  been 
adopted  by  Priestley,  contended  that  the  decidua  reflexa  is  "the 
primary  lamina  of  the  mucous  membrane,  which  when   the  ovum 


Fifi.  47. 


Fig.  48. 


Fig. 49. 


Formation  of  Decidua. 

(The  decidua  is  colored 
blaclc,  the  ovum  is  repre- 
sented as  engaged  between 
two  projecting  folds  of 
membrane.) 


Projecting  Folds   of  Membrane 
growing  up  around  the  ovum. 


(After  Dalton.) 


Showing  Ovum  completely 
surrounded  by  the  Decidua 
Eeflexa. 


enters  the  uterus,  separates  in  two-thirds  of  its  extent  from  the  layers 
beneath  it,  to  adhere  to  the  ovum  ;  the  remaining  third  remains 
attached,  and  forms  a  centre  of  nutrition."  According  to  this  view 
the  decidua  vera  would  be  a  subsequent  growth  over  the  separated 


Fig.  50. 


An  Ovum  removed  from  Uterus,  and  part  of  the  Decidua  Vera  cut  away.     (After  Coste.) 
n.  Decidua  vera,  showing  the  follicles  opening  on  its  inner  surface,     h.  Inner  extremity  of  Fallo- 
pian tube,     c.  Flap  of  decidua  reflexa.    cZ.  Ovum. 

portion,  and  the  decidua  serotina  the  portion  of  the  primary  lamina 
which  remained  attached.  In  this  way  the  fact  of  the  opposed  sur- 
faces of  the  decidua  vera  and  reflexa  being  identical  in   structure 


CONCEPTION    AND    GENERATION.  95 

would  be  accounted  for.  The  difliculty  vvliich  this  theory  is  intended 
to  meet,  does  not  seem  so  great  as  is  supposed,  for  if,  as  is  likely,  it 
is  only  the  epithelial  or  internal  surface  of  the  mucous  membrane 
which  sprouts  over  the  ovum,  and  not  its  deeper  layers,  the  facts  of 
the  case  would  be  sufficiently  met  by  Coste's  view. 

Up  to  the  third  moidh  of  preynancy  the  decidua  rejlexa  and  vera  are 
not  in  close  contact^  and  there  may  even  be  a  considerable  interspace 
between  them,  which  sometimes  contains  a  small  quantity  of  mucous 
fluid,  called  the  hydroperione.  This  fact  may  account  for  the  curious 
circumstance,  of  which  many  instances  are  on  record,  that  a  uterine 
sound  may  be  passed  into  a  gravid  uterus  in  the  early  months  of 
pregnancy  without  necessarily  producing  abortion,  and  also  for  the 
occasional  occurrence  of  menstruation  after  conception  (Figs.  50  and 
76).  Eventually,  by  the  growth  of  the  ovum,  the  decidua  reflexa 
eomes  closely  into  contact  with  the  vera,  and  the  two  become  inti- 
mately blended  and  inseparable. 

Decidua  at  the  end  of  Preynancy  and  after  Delivery. — As  pregnancy 
advances  the  decidua  alters  in  appearance  and  becomes  fibrous  and 
thin.  In  the  later  months  of  utero- gestation  fatty  degeneration  of 
its  structure  commences,  its  vessels  and  glands  are  obliterated,  and 
its  adhesion  to  the  uterine  walls  is  lessened,  so  as  to  prepare  it  for 
separation.  As  we  shall  subsequently  see,  this  fatty  degeneration 
was  assumed  by  Simpson  to  be  the  determining  cause  of  labor  at 
term. 

Views  of  Robin. — It  was  long  believed  that  the  entire  decidua  was 
thrown  off  after  labor,  leaving  the  muscular  coat  of  the  uterus  bare 
and  denuded,  and  that  a  new  mucous  membrane  was  formed  during 
convalescence.  According  to  Eobin,^  whose  views  are  corroborated 
by  Priestley,  no  such  denudation  of  the  muscular  tissue  of  the  uterus 
ever  occurs,  but  a  portion  of  the  decidua  always  remains  attached 
after  delivery.  After  the  fourth  month  of  pregnancy  they  believe 
that  a  new  mucous  membrane  is  formed  under  the  decidua,  which, 
remains  in  a  somewhat  imperfect  condition  till  after  delivery,  when 
it  rapidly  develops  and  assumes  the  proper  functions  of  the  mucous 
lining  of  the  uterus.  Eobin  also  believes  that  that  portion  of  the 
decidua  which  covers  the  placental  site,  the  so-called  decidua  scroti na, 
is  not  thrown  off  with  the  membranes,  like  the  decidua  vera  and 
reflexa,  but  remains  attached  to  the  uterine  walls,  a  thin  layer  of  it 
only  being  expelled  with  the  placenta,  on  which  it  may  be  observed. 
Duncan^  entirely  dissents  from  these  views,  and  does  not  admit  the 
formation  of  a  new  raucous  membrane  during  the  later  months  of 
utero- gestation.  He  believes  that  the  greater  portion  of  the  decidua 
is  thrown  off",  but  that  part  remains,  and  from  this  the  fresh  mucous 
membrane  is  developed.  This  view  is  similar  to  that  of  Spiegelberg, 
who  holds  that  the  portion  of  the  decidua  that  is  expelled  is  the  more 
superficial  of  the  two  layers  described  by  Friedlander,  composed 
chiefly  of  the  epithelial  elements,  while  the  deeper  or  glandular 

'  Memoires  rle  TAcarl.  Imp.  cle  Med.    1860. 
2  Researches  in  Obstetrics,  p.  18G  ot  seq. 


96  PREGNANCY. 

]ayer  remains  attached  to  the  walls  of  the  uterus.  From  the  epithe 
Hum  of  the  glands  a  new  epithelial  layer  is  rapidly  developed  after 
delivery.  This  theory  bears  on  the  well-known  analogy  of  the  uterus 
after  delivery  to  the  stump  of  an  amputated  limb;  an  old  simile, 
principally  based  on  the  erroneous  theory  that  the  whole  muscular 
tissue  of  the  uterus  was  laid  bare.  This,  as  we  have  seen,  is  not  the 
case,  but  the  simile  so  far  holds  good  in  that  the  mucous  lining  is 
deprived  of  its  epithelial  covering;  and  this  fact,  together  with  the 
existence  of  numerous  open  veins  on  the  interior  of  the  uterus,  readily 
explains  the  extreme  susceptibility  to  septic  absorption  which  forms 
so  peculiar  a  characteristic  of  the  jDuerperal  state. 

Changes  in  the  Ovum. — Before  we  commenced  the  study  of  the 
decidua  we  had  traced  the  impregnated  ovum  into  the  uterine  cavity, 
and  described  the  formation  of  the  blastodermic  membrane  by  the 
junction  of  the  cells  of  the  muriform  body.  We  must  now  proceed 
to  consider  the  further  changes  which  result  in  the  development  of 
the  foetus,  and  of  the  membranes  that  surround  it.  It  would  be 
quite  out  of  place  in  a  work  of  this  kind  to  enter  into  the  subject  of 
embryology  at  any  length,  and  we  must  therefore  be  content  with 
such  details  as  are  of  importance  from  a  practical  point  of  view. 

Division  of  the  Blastodermic  Memhrane  into  Layers. — The  blasto- 
dermic membrane,  which  forms  a  complete  spherical  lining  to  the 
ovum,  between  the  yelk  and  the  zona  pellucida,  soon  divides  into 
■two  layers,  the  most  external,  called  the  epihlast.,  and  an  internal,  the 
hypoUast.,  and  between  them  is  subsequently  developed  a  third  known 
as  the  mesohlast.  From  these  three  layers  are  formed  the  entire 
foetus;  the  epiblast  giving  origin  to  the  bones,  muscles,  and  integu- 
ments, the  nervous  system,  the  serous  membranes,  and  the  amnion; 
the  hypoblast  forming  the  mucous  membranes  and  the  alimentary 
canal;  and  the  mesoblast  the  circulating  system. 

The  Area  Germinativa. — Almost  immediately  after  the  separation 
of  the  blastodermic  membrane  into  laj^ers,  one  part  of  it  becomes 

Fig.  51. 


Diagram  of  area  gcrm'.nativa,  showing-  the  primitive  trace  and  area  pellucida. 

thickened  by  the  aggregation  of  cells,  and  is  called  the  area  germina- 
tiva.    This  is  at  first  round  and  then  oval  in  shape,  and  in  its  centre 


CONCEPTION  AND  GENERATION. 


97 


Fig.  52. 


■.•.(IdJt^^^^. 


the  first  trace  of  the  foetus  may  be  detected  in  tlic  form  of  a  narrow 
straight  line,  the  lyrvmiiive  trace.  Surrounding  it  are  some  cells  more 
translucent  than  those  of  the  rest  of  the  area  germinativa,  and  hence 
called  the  area  pellucida  (Fig.  51).  On  each  side  of  the  primitive 
trace  two  elevated  ridges  soon  arise,  the  larninbe  dorsales,  which  grad- 
ually unite  posteriorly  to  form  a  cavity  within  which  the  cerebro- 
spinal column  is  subsequently  developed.  Anteriorly  they  join  to 
form  the  thoracic  and  abdominal  cavities,  inclosing  portions  of  the 
epiblast,  from  which  the  serous  membranes  of  the  body  are  devel- 
oped. The  minute  embryo  thus  formed  soon  curves  on  itself,  with 
its  convexity  outwards,  and  a  distinct  thickening  is  observed  at  one 
end,  which  is  subsequently  developed  into  the  cephalic  extremity  of 
the  foetus,  while,  at  its  other  end,  a  thickening  less  marked  in  degree 
forms  the  caudal  extremity. 

Formation  of  the  Amnion. — -At  each  of  these  points,  very  soon  after 
the  formation  of  the  embryo,  two  hollow  processes  may  be  observed 
which  gradually  arch  over  the  dorsal 
surface  of  the  foetus,  until  they  meet 
each  other  and  form  a  complete  en- 
velope to  it.  At  the  ventral  surface 
these  processes  are  separated  by  the 
whole  length  of  the  embryo,  but  they 
here  also  gradually  approach  each 
other,  and  eventually  surround  what 
is  subsequently  the  umbilical  cord, 
and  blend  with  the  integument  of  the 
foetus  at  the  point  of  its  insertion.  In 
this  way  is  formed  the  amnion  (Fig. 
52),  consisting  of  two  layers ;  the  in- 
ternal, derived  from  the  epiblast,  is 
formed  of  tessellated  epithelial  cells, 
the  external  arising  from  the  meso- 
blast,  is  formed  of  cells  like  those  of 
young  connective  tissue.  Before  the 
folds  of  the  amnion  unite,  the  free  eds;e 
of  each  is  bent  outwards  and  spreads 
around  the  ovum,  immediately  within  the  zona  pellucida,  forming  a 
lining  to  it,  termed  by  Turner  the  sub-zonal  membrane,  which  is  con- 
nected with  the  development  of  the  chorion.  The  amnion  is  the  most 
internal  of  the  membranes  surrounding  the  foetus,  and  will  presently 
be  studied  more  in  detail.  It  soon  becomes  distended  with  fluid,  the 
liquor  amnii,  and  as  this  increases  in  amount  it  separates  the  amnion 
more  and  more  from  the  uterus. 

Changes  in  the  Mucous  La.yer. — During  this  time  the  innermost 
layer  of  the  blastodermic  membrane  or  hypoblast  is  also  developing 
two  projections  at  either  extremity  of  the  foetus,  and  these  gradually 
approach  each  other  anteriorly.  As  the  hypoblast  is  in  contact  with 
the  yelk,  when  these  meet  they  have  the  effect  of  dividing  the  yelk 
into  two  portions.  One,  and  the  smaller  of  the  two,  forms  eventu- 
ally the  intestinal  canal  of  the  foetus  ;  the  other,  and  much  the  larger, 


Develo"mo>nt  of  the  Amnion. 
1.  Vitelline  membrane.  2.  Externallayer 
of  blastodermic  membrane.  3.  Internal 
layers  formin"  the  umbilical  vesicle.  4. 
Umbilical  vessels.  5.  Projections  forming 
amnion.     6.  AUantois. 


98 


PREGNANCY. 


contains  the  greater  portion  of  the  jelk,  and  forms  the  ephemeral 
structure  known  as  the  umbilical  vesicle^  from  which  the  foetus  derives 
most  of  its  nourishment  during  the  early  stage  of  its  existence.  Its 
communication  with  the  abdominal  cavity  of  the  foetus  is  through 
the  constricted  portion  at  the  point  of  division  called  the  vitelline 
duct  (Fig.  53).  An  artery  and  vein,  the  omphalo-mesenteric,  ramify 
on  the  vesicle  and  its  duct. 

Fig.  53. 


1.  Exo-chorion.     2.  External  layer  of  blastodermic  membrane.    3.  Umbilical  vesicle.     4.  Its  vessels. 
5.  Amnion.     6.  Embiyou.     7.  Allantois  increasing  in  size. 


Fig.  54. 


As  tlie  amnion  increases  in  size,  it  pushes  back  the  umbilical 
vesical  towards  the  external  membrane  of  the  ovum,  between  which 
and  the  amnion  it  lies  (Fig.  54) ;  and  when  the 
allantois  is  developed,  it  ceases  to  be  of  any  use, 
and  rapidly  shrinks  and  dwindles  away.  In 
most  mammals  no  trace  of  it  can  be  found  after 
the  fourth  month  of  utero-gestation  ;  in  some, 
including  the  human  female,  it  is  said  to  exist 
as  a  minute  vesicle  at  the  placental  end  of  the 
umbilical  cord  at  the  full  period  of  pregnancy. 
The  umbilical  vesicle  is  filled  with  a  yellowish 
fluid,  containing  many  oil  and  fat  globules,  simi- 
lar to  the  yelk  of  an  egg. 

The  Allantois. — Somewhere  about  the  twen- 
tieth day  after  conception  a  small  vesicle  is 
formed  toward  the  caudal  extremity  of  the 
foetus,  which  is  called  the  allantois.  It  is  well 
developed  and  persistent  in  many  of  the  lower 
animals,  but  in  man  it  is  merely  a  temporary 
structure,  and  disappears  after  it  has  fulfilled  its 
functions.  Its  study,  therefore,  in  the  human 
race  has  been  a  matter  of  difficulty,  and  it  was  long  before  we  were 
possessed  of  any  very  reliable  information  regarding  it.  There  has 
been   some  difference  of  opinion  as  to  its  precise  mode   of  origin. 


An  Embryo  of  about 
twenty-five  days  laid  open. 
(After  Coste.) 

(I.  Chorion,  h.  Amnion. 
c.  Cavity  of  chorion,  d. 
tJmbilical  vesicle,  e.  Pedi- 
cle of  allantois.  /.  Em- 
biyo. 


CONCEPTION    AND    GENERATION. 


99 


The  most  generally  received  opinion  is  that  it  begins  as  a  divertic- 
ulum from  the  lower  part  of  the  intestinal  canal.  This,  at  first 
spherical,  rapidly  develops  and  becomes  pyriforra  in  shape,  while,  by 
a  process  of  constriction,  similar  to  that  which  occurs  in  the  vitellus 
to  form  the  umbilical  vesical,  it  becomes  divided  into  two  parts,  com- 
municating with  each  other,  the  smaller  of  them  being  eventually 
developed  into  the  urinary  bladder.  The  larger  portion,  leaving  the 
abdominal  cavity  along  with  the  vitelline  duct,  rapidly  grows  until 
it  comes  into  contact  with  the  most  external  ovular  membrane,  the 
chorion,  over  the  entire  inner  surface  of  which  it  spreads.  In  this 
part  vessels  soon  develop  :  namely,  the  two  umbilical  arteries,  de- 
rived from  the  abdominal  aorta,  and  two  umbilical  veins,  one  of 
which  subsequently  disappears ;  these,  along  Avith  the  vitelline  duct 
and  the  pedicle  of  the  allantois,  form  the  umbilical  cord.  The  main 
and  very  important  function  of  the  allantois,  therefore,  is  to  carry 
the  foetal  vessels  up  to  the  inner  surface  of  the  sub-zonal  membrane. 

Fig.  55. 


1.  Exo-chorion.     2,  External  layer  of  the  blastodermic  membrane.     3.  Allantois.     4.  Umbilical 
vesical.    6.  Amnion.     6.  Embryon.     7.  Pedicle  of  Allantois. 


Besides  this  purpose,  the  allantois,  at  a  very  early  period,  may  receive 
the  excretions  of  the  foetus,  and  serve  as  an  excrementitious  organ. 
According  to  Cazeaux,  scarcely  a  trace  of  the  allantois  can  be  seen 
a  few  clays  after  its  formation.  Its  lower  part  or  pedicle,  however, 
long  remains  distinct,  and  forms  part  of  the  umbilical  cord ;  and 
traces  of  it  may  be  found  oven  in  adult  life  in  the  form  of  the  urachus, 
which  is  really  the  dwindled  pedicle,  and  forms  one  of  the  ligaments 
of  the  bladder. 

The  Corps  Reticule  or  Yitriform  Body. — Between  the  chorion  and 
amnion  is  often  found  a  gelatinous  fluid,  with  minute  filamentous 
processes  traversing  it,  called  by  Yelpeau  the  corps  reticuU  which  is 
not  met  with  until  the  allantois  comes  into  contact  with  the  chorion, 
and  which  seems  to  be  formed  out  of  the  tissues  of  that  vesicle.  It 
is  analogous  to  the  so-called  Wharton's  jelly  found  in  the  umbilical 


100  PREGNANCY. 

cord.  When  first  formed  it  is  highly  vascular,  but  the  vessels 
entirely  disappear  after  the  placenta  is  formed,  and  the  remainder  of 
the  chorionic  villi  atrophy.  Sometimes  it  exists  in  considerable 
quantities,  and  should  the  chorion  rupture  at  the  end  of  pregnancy, 
it  may  escape  and  give  rise  to  an  erroneous  impression  that  the 
liquor  amnii  has  been  discharged. 

Recapitulation. — Before  proceeding  to  consider  the  foetal  envelopes 
more  at  length,  it  may  be  useful  to  recapitulate  the  structures  already 
alluded  to  as  forming  the  ovum.     In  this  we  find : — 

1.  The  emhryo  itself. 

2.  A  fluid,  the  liquor  avinii,  in  which  it  floats. 

3.  The  amnion,  a  purely  foetal  membrane  surrounding  the  embryo, 
and  containing  the  liquor  amnii. 

4.  The  umhilical  vesicle,  containing  the  greater  portion  of  the  yelk, 
serving  as  a  source  of  nutrition  to  the  early  embryo  through  the 
vitelline  duct,  and  in  which  ramify  the  omphalo-mesenteric  vessels. 

5.  The  allantois,  a  vesicle  proceeding  from  the  caudal  extremity 
of  the  embryo,  spreading  itself  over  the  interior  of  the  ovum,  and 
serving  as  a  channel  of  vascular  communication  between  the  chorion 
and  the  foetus,  through  the  umbilical  vessels. 

6.  An  interspace  between  the  outer  layer  of  the  ovum  and  the 
amnion,  in  which  is  contained  the  umhilical  vesicle  and  allantois,  and 
the  corps  reticule,  of  Yelpeau. 

7.  The  outer  layer  of  the  ovum,  along  with  the  sub-zonal  mem- 
brane, forming  the  chorio7i  and  placenta. 

Amnion. — 'The  amnion  is  the  most  internal  of  the  two  membranes 
surrounding  the  foetus ;  its  origin  at  an  early  period  of  foetal  life  has 
already  been  described.  It  is  a  perfectly  smooth,  transparent,  but 
tough  membrane,  continuous  with  the  integument  of  the  foetus  at  the 
insertion  of  the  umbilical  cord,  round  which  it  forms  a  sheath.  Soon 
after  it  is  formed  it  becomes  distended  with  a  fluid,  the  liquor  amnii, 
in  which  the  foetus  is  suwspended  and  floats.  This  fluid  increases 
gradually  in  quantity,  distending  the  amnion  as  it  does  so,  until  this 
is  brought  into  contact  with  the  inner  surface  of  the  chorion,  from 
which  it  was  at  first  separated  by  a  considerable  interspace. 

Structure. — The  internal  surface  of  the  amnion  is  smooth  and 
glistening,  and  on  microscopic  examination  it  is  found  to  consist  of 
a  layer  of  flattened  cells,  each  containing  a  large  nucleus.  These 
rest  on  a  stratum  of  fibrous  tissae  which  gives  to  the  membrane  its 
toughness,  and  b}^  which  it  is  attached  to  the  inner  surface  of  the 
chorion.  It  is  entirely  destitute  of  vessels,  nerves,  and  lymphatics. 
The  quantity  of  the  liquor  amnii  varies  much  at  different  periods  of 
pregnancy.  In  the  early  months  it  is  relatively  greater  in  amount 
than  the  foetus,  which  it  outweighs.  As  pregnancy  advances,  the 
weight  of  the  foetus  becomes  four  or  five  times  greater  than  that  of 
the  liquor  amnii,  although  the  actual  quantity  of  fluid  increases  dur- 
ing the  whole  period  of  gestation.  The  amount  of  fluid  varies  much 
in  different  pregnancies.  Sometimes  there  is  comparatively  little ; 
while  at  others  the  quantity  is  immense,  reaching  several  pounds 


CONCEPTION  AND  GENERATION.  '  101 

in  weight,  greatly  distending  the  uterus,  and  thus,  it  may  be  pro- 
ducing difficulty  in  labor. 

Its  Quality. — At  first  the  liquid  is  clear  and  limpid.  As  pregnancy 
advances  it  becomes  more  turbid  and  dense,  from  the  admixture  of 
epithelial  debris  derived  from  the  cutaneous  surface  of  the  foetus. 
In  some  cases,  without  actual  disease,  it  may  be  dark  green  iu  color, 
and  thick  and  tenacious  in  consistency.  It  has  a  peculiar  heavy 
odor,  and  it  consists  chemically  of  water  containing  albumen,  with 
various  salts,  principally  phosphates  and  chlorides. 

Its  Source. — The  source  of  the  liquor  amnii  has  been  much  disputed. 
Some  maintain  that  it  is  derived  chiefly  from  the  foetus,  a  view  suffi- 
ciently disproved  by  the  fact  that  the  liquor  amnii  continues  to  in- 
crease in  amount  after  the  death  of  the  foetus.  Burdach  believed 
that  it  is  secreted  by  the  internal  surface  of  the  uterus,  and  arrives 
in  the  cavity  of  the  amnion  by  transudation  through  the  membrane. 
Priestley — and  this  seems  the  most  probable  hypothesis — thinks  that 
it  is  secreted  by  the  epithelial  cells  lining  the  membrane,  which 
become  distended  with  fluid,  burst,  and  pour  their  contents  into  the 
amniotic  cavity. 

Functions  and  Uses. — The  most  obvious  use  of  the  liquor  amnii  is 
to  afford  a  fluid  medium  in  which  the  foetus  floats,  and  so  is  protected 
from  the  shocks  and  jars  to  which  it  would  otherwise  be  subjected, 
and  from  undue  pressure  from  the  uterine  walls.  By  distending  the 
uterus  it  saves  the  uterus  from  injury,  which  the  movements  of  the 
foetus  might  otherwise  inflict,  and  the  foetus  is  thus  also  enabled  to 
change  its  position  freely.  The  facility  with  which  version  by  ex- 
ternal manipulation  can  be  effected  depends  entirely  on  the  mobility 
of  the  foetus  in  the  fluid  which  surrounds  it.  Some  have  also  supposed 
that  it  prevents  the  foetus,  in  the  early  months  of  pregnancy,  from 
forming  adhesions  to  the  amnion.  In  labor  it  is  of  great  service,  by 
lubricating  the  passages,  but  chiefly  by  forming,  with  the  membranes, 
a  fluid  wedge,  which  dilates  the  circle  of  the  os  uteri. 

Chorion. — The  chorion  is  the  more  external  of  the  truly  foetal  mem- 
branes, although  external  to  it  is  the  decidua,  having  a  strictly  ma- 
ternal origin.  It  is  a  perfectly  closed  sac,  its  external  surface,  in 
contact  with  the  decidua,  being  rough  and  shaggy  from  the  develop- 
ment of  villi  (Fig.  51),  its  internal  smooth  and  shinning.  As  the 
ovum  passes  along  the  Fallopian  tube  it  receives,  as  we  have  seen, 
an  albuminous  coating,  and  this,  with  the  zona  pellucida,  is  devel- 
oped into  a  temporary  structure,  the  'priraitive  chorion.  On  its  exter- 
nal surface  villous  prominences  soon  appear,  which  have  no  ascer- 
tained structure,  and  which  seem  to  supply  the  early  ovum  with 
nutriment  by  endosmotic  absorption  from  the  mucous  membrane  of 
the  uterus.  This  primitive  chorion,  however,  has  not  been  observed 
in  the  human  subject,  although  it  may  be  readily  seen  in  the  ova  of 
some  of  the  lower  animals,  such  as  the  dog  and  the  rabbit.  Some 
twelve  days  after  conception,  when  the  blastodermic  membrane  is 
formed,  the  true  chorion  appears.  This  is,  in  fact  formed  by  the 
epiblast  layer  of  the  blastodermic  membrane,  which  everywhere  lines 
the  zona  pellucida  or  primitive  chorion,  and,  by  pressure,  causes  its 


102  PREGNANCY. 

absorption  and  disappearance.  On  tlie  surface  of  the  true  chorion 
thus  formed,  which  is  now  the  external  envek)pe  of  the  ovum,  villi 
soon  appear. 

Formation  of  the  Villi. — These  villi  are  hollow  projections  like  the 
fingers  of  a  glove,  which  are  raised  up  from  the  surface  of  the  cho- 
rion (the  hollows  looking  into  the  chorionic  cavity),  and  thev  cover 
the  whole  external  surface  of  the  ovum,  giving  it  the  peculiar'shaggy 
appearance  observed  in  early  abortions.  They  push  themselves  into 
the  substance  of  the  decidua,  with  which  they  soon  become  so  firmly 
united  that  they  cannot  be  separated  without  laceration.  At  first 
they  are  absolutely  non-vascular,  but  soon  the  allantois,  previously 
described,  reaches  the  inner  surface  of  the  chorion,  and  spreads  itself 
over  the  whole  of  it.  Each  villus  now  receives  a  separate  artery  and 
vein,  which  gives  off  a  branch  to  each  of  the  subdivisions  into  which 
\h.Q  villus  divides.  These  vessels  are  encased  in  a  fine  sheath  of  the 
allantois  which  enters  the  villus  along  with  them  and  forms  a  lining 
to  it,  described  by  some  as  the  endochorion ;  the  external  epithelial 
membrane  of  the  villus,  derived  from  the  epiblast  layer  of  the  blasto- 
dermic membrane,  being  called  the  exo-chorion.  The  artery  and 
vein  lie  side  by  side  in  the  centre  of  the  villus  and  anastomose  at  its 
extremity ;  each  villus  thus  having  a  separate  circulation. 

Grozvth  and  Atrophy  of  the  Villi. — -As  soon  as  the  union  of  the 
allantois  with  the  chorion  has  been  effected,  the  villi  grow  verv 
rapidly,  give  off  branches,  which,  in  their  turn,  give  off  secondarv 
branches,  and  so  form  root-like  processes  of  great  complexity.  In 
the  early  months  of  gestation  they  exist  equally  over  the  whole  sur- 
face of  the  ovum.  As  pregnancy  advances,  however,  those  which  are 
in  contact  with  the  decidua  reflexa  shrivel  up,  and,  by  the  end  of  the 
second  month,  disappear,  being  no  longer  required  for  the  nutrition 
of  the  ovum.  The  chorion  and  decidua  thus  come  into  close  contact, 
being  united  together  by  fibrous  shreds,  Avhich,  on  microscopic  ex- 
amination, are  found  to  consist  of  the  atrophied  villi.  A  certain 
number  of  the  villi,  viz.,  those  which  are  in  contact  with  the  decidua 
serotina,  instead  of  dwindling  away  increase  greatly  in  size,  and 
eventually  develop  into  the  organ  by  which  the  foetus  is  nourished 
— the  'placenta. 

Form  of  the  Placenta. —  This  important  organ  serves  the  purpose 
of  supplying  nutriment  to,  and  aerating  the  blood  of  the  foetus,  and 
on  its  integrity  the  existence  of  the  foetus  depends.  It  is  met  with 
in  all  mammals,  but  is  very  different  in  form  and  arrangement  in 
different  classes.  Thus,  in  the  sow,  mare,  and  in  the  cetacea,  it  is 
diffused  over  the  whole  interior  of  the  uterus  ;  in  the  ruminants,  it 
is  divided  into  a  number  of  separate  small  masses,  scattered  here  and 
there  over  the  uterine  walls ;  while  in  the  carnivora  and  elephant,  it 
forms  a  zone  or  belt  round  the  nterine  cavity.  In  the  human  race, 
as  well  as  in  rodentia,  insectivora,  etc.,  the  placenta  is  in  the  form  of 
a  circular  mass,  attached  generally  to  some  part  of  the  uterus  near 
the  orifices  of  the  Fallopian  tubes ;  but  it  may  be  situated  anywhere 
in  the  uterine  cavity,  even  over  the  internal  os  uteri.  As  it  is  ex- 
pelled after  delivery  with  the  foetal  membranes  attached  to  it,  and  as 


CONCEPTION    AND    GENERATION.  103 

the  aperture  in  these  corresponds  to  the  os  uteri,  we  can  generally 
determine  pretty  accurately  the  situation  in  wliicli  the  placenta  was 
placed,  by  examining  them  after  expulsion.  The  maternal  surface 
of  the  placenta  is  somewhat  convex,  the  foetal  concave.  Its  size 
varies  greatly  in  different  cases,  and  it  is  usually  largest  when  the 
child  is  big,  but  not  necessarily  so.  Its  average  diameter  is  from 
six  to  eight  inches,  its  weight  from  18  to  24  oz.,  but,  in  exceptional 
cases,  it  has  been  found  to  weigh  several  pounds.  Abnormalities  of 
form  are  not  very  rare.  Thus,  tlie  placenta  has  been  found  to  be 
divided  into  distinct  parts,  a  form  said  by  Professor  Turner  to  be 
normal  in  certain  genera  of  monkeys;  or  smaller  supplementary 
placenta3  {placenise  _  succentariye),  may  exist  round  a  central  mass. 
These  variations  of*  shape  are  only  of  importance  in  consequence  of 
a  risk  of  part  of  the  detached  placenta  being  left  in  utero  after 
delivery,  and  giving  rise  to  septicaemia  or  secondary  hemorrhage. 

Attachment  of  the  Membranes. — The  foetal  membi-anes  cover  the 
whole  fostal  surface  of  the  placenta,  being  reflected  from  its  edges  so 
as  to  line  the  uterine  cavity,  and  being  expelled  with  it  after  delivery. 
They  also  leave  it  at  the  insertion  of  the  cord,  to  which  they  form  a 
sheath.  The  cord  is  generally  attached  near  the  centre  of  the  placenta, 
and  from  its  insertion  the  umbilical  vessels  may  be  seen  dividing 
and  radiating  over  the  whole  foetal  surface. 

Its  Maternal  Surface. — The  maternal  surface  is  rough  and  divided 
by  numerous  sulci,  which  are  best  seen  if  the  placenta  is  rendered 
convex,  so  as  to  resemble  its  condition  when  attached  to  the  uterus. 
A  careful  examination  shows  that  a  delicate  membrane  covers  the 
entire  maternal  surface,  unites  the  sulci  together,  and  dips  down  be- 
tween them.  This  is,  in  fact,  the  cellular  layer  of  the  decidua  sero- 
tina,  which  is  separated  and  expelled  with  the  placenta,  the  deeper 
layer  remaining  attached  in  utero.  Numerous  small  openings  may 
be  seen  on  the  surface,  which  are  the  apertures  of  the  veins  torn  off 
from  the  uterus,  as  also  those  of  some  arteries,  which,  after  taking 
several  sharp  turns,  open  suddenly  into  the  substance  of  the  organ. 

Minute  Structure  of  the  Placenta. — As  regards  the  minute  structure 
of  the  placenta  it  is  certain  that  it  consists  essentially  of  two  dis- 
tinct portions,  one  foetal^  consisting  of  the  greatly  hypertrophied 
chorionic  villi,  with  their  contained  vessels,  which  carry  the  fcetal 
blood  so  as  to  brins;  it  into  intimate  relation  with  the  maternal  blood, 
and  thus  admit  of  the  necessary  changes  occurring  in  it  connected 
with  the  nutrition  of  the  foetus;  and  the  other  raaternaf  formed  out 
of  the  decidua  serotina  and  the  maternal  bloodvessels.  These  two 
portions  are  in  the  human  female  so  intimately  blended  as  to  form 
the  single  deciduous  organ  which  is  throAvn  off  after  delivery.  These 
main  facts  are  admitted  by  all,  but  considerable  differences  of  opinion 
still  exist  among  anatomists  as  to  the  precise  arrangement  of  these 
parts.  In  the  following  sketch  of  the  subject  I  shall  describe  the 
views  most  generally  entertained,  merely  briefly  indicating  the  points 
which  are  contested  by  various  authorities. 

.  Foetal  Portion  of  the  Placenta, — The  foetal  portion  of  the  placenta 
consists  essentially  of  the  ultimate  ramifications  of  the  chorion  villi. 


104 


PREGNANCY, 


which  may  be  seen  on  microscopic  examination  in  the  form  of  club- 
shaped  cligitations  which  are  given  off'  at  every  possible  angle  from 
the  stem  of  a  parent  trunk,  just  like  the  branches  of  a  plant.  With- 
in the  transparent  walls  of  the  villi  the  capillary  tubes  of  the  con- 
tained vessels  may  be  seen  lying,  distended  with  blood,  and  present- 
ing an  appearance  not  unlike  loops  of  small  intestine.  The  capilla- 
ries are  the  terminal  ramifications  of  the  umbilical  arteries  and  veins, 
which,  after  reaching  the  site  of  the  placenta,  divide  and  subdivide 
until  they  at  last  form  an  immense  number  of  minute  capillary 
vessels,  with  their  convexities  looking  towards  the  maternal  portion 
of  the  placenta,  each  terminal  loop  being  contained  in  one  of  the 
digitations  of  the  chorionic  villi.  Bach  arterial  twig  is  accompanied 
by  a  corresponding  venous  branch,  which  unites  with  it  to  form  the 
terminal  arch  or  loop  (Fig.  56).     The  foetal  blood  is  carried  through 


Placental  ViUus,  greatly  magnified.     (After  Jouliu.) 
1,  2.  Placental  vessels,  forming  terminal  loops.    3.  Chorion  tissue,  forming  external  walls  of  villus. 
4.  Tissue  surrounding  vessels. 

these  arterial  twigs  to  the  villi,  where  it  comes  into  intimate  contact 
with  the  maternal  blood,  in  consequence  of  the  anatomical  arrange- 
ments presently  to  be  described ;  but  the  two  do  not  directly  mix,  as 
the  older  physiologists  believed,  for  none  of  the  maternal  blood 
escapes  when  the  unibilical  cord  is  cut,  nor  can  the  minutest  injections 
through  the  foetal  vessels  be  made  to  pass  into  the  maternal  vascular 
system,  or  vice  versa.  In  addition  to  the  looped  terminations  of  the 
umbilical  vessels,  Farre  and  Schroeder  van  der  Kolk  have  described 
another  set  of  capillary  vessels  in  connection  with  each  villus  (Fig. 


CONCEPTION    AND    GENERATION. 


106 


57).     This  consists  of  a  very  fine  network  covering  each  villus,  and 
very  different  in  appearance  from  the  convoluted  vessels  lying  iu  its 


Fig.  57. 


a.  TermiDiil  viUus  of  fcctal  tuft,  miautely  injected.     6.  Its  nucleated  noii- vascular  sheath. 

(After  Faire.) 

interior,  which  are  the  only  ones  which  have  been  usuall}'  described. 
Dr.  Far  re  believes  that  these  vessels  only  exist  in  the  early  months  of 

Fig.  58. 


c^  c  s- 

biagram  representing  a  Vertical  Section  of  the  Placenta.     (After  Dalton.) 
a.,  a.  Chorion.     6,  h.  Decidua.    e,  c,  c,  e.  Orifices  of  uterine  sinuses. 

pregnancy,  and  that  they  disappear  as  pregnancy  advances.    Priestlev' 
suggests  that  they  may  not  be  vessels  at  all,  iDut  lymphatics,  which 

1  The  Gravid  Uterus,  p.  52. 


106 


PREGNANCY, 


may  possibly  absorb  nutrient  material  from  the  mother's  blood,  and 
throw  it  into  the  foetal  vascular  system.  The  existence  of  lymphatics, 
or  nerves,  in  the  placenta,  however,  has  never  been  demonstrated, 
and  they  are  believed  not  to  exist. 

Maternal  Portion  of  the  Placenta. — As  generally  described,  the 
maternal  portion  of  the  placenta  consists  of  large  cavities,  or  of  a 
single  large  cavity,  which  contain  the  maternal  blood,  and  into  which 
the  villi  of  the  chorion  penetrate  (Fig.  58).  Into  this  maternal  part 
of  the  viscQs  the  curling  arteries  of  the  uterus  pour  their  blood, 
which  is  collected  from  it  by  the  uterine  sinuses.  The  villi  of  the 
chorion,  therefore,  are  suspended  in  a  sac  filled  with  maternal  blood, 
which  penetrates  freely  between  them,  and  with  which  they  are 
brought  into  very  intimate  contact.  Dr.  John  Eeid  beheved  that 
only  the  delicate  internal  lining  of  the  maternal  vessels  entered  the 
substance  of  the  placenta,  to  form  the  sac  just  s])oken  of.  Into  this 
the  villi  project,  pushing  before  them  the  membrane  forming  the 
limiting  wall  of  the  placental  sinuses,  each  of  them  in  this  way  re- 
ceiving an  investment,  just  as  the  fingers  of  a  hand  are  covered  by 
a  glove  (Fig.  59). 


Fig.  59. 


Fig.  60. 


C— -^^ 


Diagram  iUustratiiig  the  mode  in  whicli  a  pla- 
cental villus  derives  a  coveriug  from  the  vascu- 
lar system  of  the  mother.     (After  Priestley.) 

a.  Villus  having  three  terminal  digitations  pvo- 
jpcting  into  6.  Cavity  of  the  mother's  vessel,  c. 
Dotted  liues  representing  coat  of  vessel. 


The  Extremity  of  a  Placental  Villus. 

(After  Goodsir.) 
a.  External  membrane  of  villus  (the  lining 
membrane  of  vascular  system  of  Weber). 

h.    External  cells   of  villus    derived   from 
decidua. 

e,  c.  Nuclei  of  ditto. 

d.    The  space  between   the   maternal  and 
fcetal  portions  of  villus. 
e.  Its  interual  membrane. 
/.  Its  internal  cells. 
g.  The  loop  of  umbilical  vessels. 


Theortj  of  Goodsir.— ^chvoed^QY  van  der  Kolk  and  Goodsir  (Fig.  60) 
were  of  opinion  that  not  only  were  the  maternal  bloodvessels  con- 
tinued into  the  substance  of  the  placenta,  but  also  the  processes  of 
the  decidua,  which  accompanied  the  vessels  and  were  prolonged  over 
each  villus,  so  as  to  separate  it  from  the  limiting  membrane  of  the 
maternal  sinuses.  Each  villus  would  thus  be  covered  by  tAvo  layers 
of  fine  tissue,  one  from  the  internal  lining  membrane  of  the  maternal 
bloodvessels,  the  other  from  the  epithelial  cells  of  the  decidua. 

Theory  of  2'Mr?zer.— Turner,  whose  valuable  researches  on  the  com- 
parative anatomy  of  the  placenta  have  thrown  much  light  on  its 


CONCEPTION    AND    GENERATION.  107 

structure,  points  out  that  the  placentae  of  all  animals  are  formed  on 
the  same  fundamental  type,'  in  which  the  foeial  portion  consists  of  a 
smooth,  plane-surfaced  vascular  membrane,  covered  with  pavement 
epithelium,  which  is  brought  into  contact  with  the  mrxternal portion, 
consisting  of  a  smooth,  plane-surfaced  vascular  membrane,  covered 
with  columnar  epithelium.  The  foetal  capillaries  are  separated  from 
the  maternal  capillaries  onlj  by  two  opposed  layers  of  epithelium. 
In  various  animals  the  placentas  are  more  or  less  specialized  from 
the  generalized  form,  in  some  to  a  much  greater  extent  than  others. 
In  the  human  placenta  the  maternal  vessels  have  lost  their  normal 
cylindrical  form,  and  are  dilated  into  a  system  of  freely  intercom- 
municating placental  sinuses,  which  are,  in  fact,  maternal  capillaries 
enormously  enlarged,  with  their  walls  so  expanded  and  thinned  out 
that  they  cannot  be  recognized  as  a  distinct  layer  limiting  the  sinus. 
Each  foetal  chorionic  villus  projecting  into  these  sinuses  is  covered 
with  a  layer  of  cells  distinct  from  those  of  the  epithelial  layer  of  the 
villus,  and  readily  stripped  from  it.  These  are  maternal  in  their 
origin,  and  are  derived  from  the  decidua,  which  sends  prolongations 
of  its  tissue  into  the  placenta.  These  cells,  he  believes  form  a  secret- 
ing epithelium  which  separates  from  the  maternal  blood  a  secretion 
for  the  nourishment  of  the  foetus,  which  is,  in  its  turn,  absorbed  by 
the  villi  of  the  chorion. 

Theory  of  Ercolani. — A  view  not  very  dissimilar  to  this  has  been 
advanced  by  Professor  Ercolani  of  Bologna,  who  maintains  that  the 
maternal  portion  of  the  placenta  is  a  new  formation,  strictly  glandu- 
lar, and  not  vascular,  in  its  structure.  It  is  formed,  he  thinks,  by 
the  submucous  connective  tissue  of  the  decidua  serotina,  and  it  dips 
down  into  the  placenta  and  forms  a  sheath  to  each  of  the  chorion 
villi,  which  it  separates  from  the  maternal  blood.  This  new  glandu- 
lar structure  he  describes  as  secreting  a  fluid,  termed  the  "  uterine 
milk,"  which  is  absorbed  by  the  villi  of  the  chorion,  just  as  the 
mother's  milk  is  absorbed  by  the  villi  of  the  intestines,  and  it  is  with 
this  fluid  alone  that  the  chorion  villi  are  in  direct  contact.  The  sheath 
thus  formed  to  each  villus  is  doubtless  analogous  to  the  layer  of  cells 
which  Goodsir  described  as  encasing  each  villus,  but  is  attributed  to 
a  new  structure  formed  after  conception. 

Theory  of  Braxton  Hichs. — The  existence  of  the  maternal  sinus 
system  in  the  placenta,  is  altogether  denied  by  anatomists  of  emi- 
nence whose  views  are  worthy  of  careful  consideration.  Prominent 
amongst  these  is  Braxton  Hicks,^  who  has  written  an  elaborate  paper 
on  the  subject.  He  holds  that  there  is  no  evidence  to  prove  that  the 
maternal  blood  is  poured  out  into  a  cavity  in  whicli  the  chorion  villi 
float,  and  he  believes  that  the  curling  arteries,  instead  of  entering 
the  so-called  maternal  portion  of  the'placenta,  terminate  in  the  de- 
cidua serotina.  The  hypertrophied  chorion  villi  at  the  site  of  the 
placenta  are  firmly  attached  to  the  decidual  surface,  into  which  their 
tips  are  imbedded.  The  line  of  junction  between  the  decidua  reflexa 
and  serotina  forms  a  circumferential  margin  to,  and  limits  the  pla- 

'  Introduction  to  Human  Anatomy,  part  2.  2  Obst.  Trans.,  vol.  xiv. 


108  PREGNANCY. 

centa.  The  arrangement  of  the  foetal  portion  of  the  placenta  on  this 
view  is  very  similar  to  that  generally  described,  but  the  villi  are  not 
surrounded  by  maternal  blood  at  all,  and  nothing  exists  between 
them,  unless  it  be  a  small  quantity  of  serous  fluid.  The  change  in 
the  foetal  blood  is  effected  by  endosmosis,  and  Hicks  suggests  that 
follicles  of  the  decidua  may  secrete  a  fluid,  which  is  poured  into  the 
intervillous  spaces  for  absorption  by  the  villi. 

Functions  of  the  Placenta. — It  will  thus  be  seen  that  anatomists  of 
repute  are  still  undecided  as  to  important  points  in  the  minute  ana- 
tomy of  the  placenta,  which  further  investigation  will  doubtless 
clear  up.  The  main  functions  of  the  organ  are,  however,  sufficiently 
clear.  During  the  entire  period  of  its  existence  it  fills  the  important 
ofl&ce  of  both  stomach  and  lungs  to  the  foetus.  Whatever  view  of 
the  arrangement  of  the  maternal  bloodvessels  be  taken,  it  is  certain 
that  the  foetal  blood  is  propelled  by  the  pulsations  of  the  foetal  heart 
into  the  numberless  villi  of  the  chorion,  where  it  is  brought  into 
very  intimate  relation  with  the  mother's  blood,  gives  off  its  carbonic 
acid,  absorbs  oxygen,  and  passes  back  to  the  foetus,  through  the  um- 
bilical veins,  in  a  fit  state  for  circulation.  The  mode  of  respiration, 
therefore,  in  the  foetus  is  analogous  to  that  in  fishes,  the  chorion  villi 
representing  the  gills,  the  maternal  blood  the  water  in  which  they 
float.  Nutrition  is  also  effected  in  the  organ,  and,  by  absorption 
through  the  chorion  villi,  the  pabulum  for  the  nourishment  of  the 
foetus  is  taken  up.  It  also  probably  serves  as  an  emunctory  for  the 
products  of  excretion  in  the  foetus.  Picard  found  that  the  blood  in 
the  placenta  contained  an  appreciably  larger  quantity  of  urea  than 
that  in  other  parts  of  the  body,  this  urea  probably  being  derived 
from  the  foetus.  Claude  Bernard  also  attributed  to  it  a  glycogenic 
function,^  supposing  it  to  take  the  place  of  the  foetal  liver  until  that 
organ  was  sufficiently  developed. 

Degenerative  Changes  previous  to  Expulsion. — Finally,  we  find  that 
the  temporary  character  of  the  placenta  is  indicated  by  certain  degen- 
erative changes,  which  take  place  in  it  previous  to  expulsion.  These 
consist  chiefly  in  the  deposit  of  calcareous  patches  on  its  uterine  sur- 
face, and  in  fatty  degeneration  of  the  villi,  and  of  the  decidual  layer 
between  the  placenta  and  the  uterus.  If  this  degeneration  be  carried 
to  excess,  as  is  not  unfrequently  the  case,  the  foetus  may  perish  from 
a  want  of  a  sufficient  number  of  healthy  villi  through  which  its 
respiration  and  nutrition  may  be  effected. 

Umhih'cal  Cord.- — The  umbilical  cord  is  the  channel  of  communi- 
cation between  the  foetus  and  placenta,  being  attached  to  the  former 
at  the  umbilicus,  to  the  latter  generally  near  its  centre,  but  some- 
times, as  in  the  battledore  placenta,  at  its  edge.  It  varies  much  in 
length,  measuring  on  an  average  from  18  to  24  inches,  but  in  excep- 
tional cases  being  found  as  long  as  50  or  60,  and  as  short  as  5  or  6 
inches. 

When  fully  formed  it  consists  of  an  external  membranous  layer 
formed  of  the  amnion,  two  umbilical  arteries,  one  umbilical  vein,  and 

'  Acad,  des  Sciences,  April,  1859. 


ANATOMY    AND    PHYSIOLOGY    OF    THE    FCETUS.  109 

a  considerable  quantity  of  transparent  gelatinous  substance  surround- 
ing the  vessels,  called  Wharton's  jelly,  which  is  contained  in  a  fine 
network  of  fibres,  and  is  formed  out  of  the  tissue  of  the  allantois. 
At  an  early  period  of  pregnancy,  in  addition  to  these  structures,  the 
cord  contains  the  pedicle  of  the  umbilical  vesicle,  with  the  omphalo 
mesenteric  vessels  ramifying  on  it,  and  two  umbilical  veins,  one  of 
which  soon  atrophies  and  disappears.  No  nerves  or  lymphatics  have 
been  satisfactorily  demonstrated  in  the  cord,  although  such  have 
been  described  as  existing.  The  vessels  of  the  cord  are  at  first 
straight  in  their  course,  but  shortly  they  become  greatly  twisted,  the 
arteries  being  external  to  the  vein,  and  in  nine  cases  out  of  ten  the 
twist  is  from  left  to  right.  Various  explanations  have  been  given  of 
this  peculiarity,  none  of  them  entirely  satisfactory.  Tyler  Smith 
attributed  it  to  the  movements  of  the  foetus  twisting  the  cord,  its 
attacliment  to  the  placenta  being  a  fixed  point ;  this  would  not,  how- 
ever, account  for  the  frequency  with  which  the  spiral  turns  occur  in 
one  direction.  Mr.  John  Simpson  attributed  it  to  the  greater  pres- 
sure of  the  blood  through  the  right  hypogastric  artery,  on  account 
of  that  vessel  having  a  more  direct  I'elation  to  the  aorta  than  the 
left.  The  vimbilical  arteries  give  off  no  branches,  and  the  vein  con- 
tains no  valves,  nor  can  any  vasa  vasorum  be  detected  in  their  coats 
after  they  have  left  the  umbilicus.  The  umbilical  arteries  increase 
in  size  after  they  leave  the  cord,  to  divide  on  the  surface  of  the  pla- 
centa. This  is  the  only  example  in  the  body  in  which  arteries  are 
larger  near  their  terminations  than  their  origin,  and  the  object  of 
this  arrangement  is  probably  to  effect  a  retardation  of  the  current  of 
the  blood  distributed  to  the  placenta.  The  tortuous  course  of  the 
vein  probably  compensates  for  the  absence  of  valves,  and  moderates 
the  flow  of  blood  through  it.  Distinct  knots  are  not  unfrequently 
observed  in  the  cord,  but  they  rarely  have  the  effect  of  obstructing 
the  circulation  through  it.  They  no  doubt  form  when  the  foetus  is 
very  small.  They  may  sometimes  also  be  produced  in  labor  by  the 
child  being  propelled  through  a  coil  of  the  cord  lying  circularly  round 
the  OS  uteri.  The  so  called  false  knots  are  merely  accidental  nodosi- 
ties due  to  local  enlargements  of  the  vessels. 


CHAPTEE    II. 

THE    ANATOMY   AND   PHYSIOLOGY    OF   THE    FCETUS. 

It  is  obviously  impossible  to  attempt  anything  like  a  full  account 
of  the  development  of  the  various  foetal  structures,  or  of  their  growth 
during  intra-uterine  life.  To  do  so  would  lead  us  far  beyond  the 
scope  of  this  work,  and  would  involve  a  study  of  complex  details 


110  PREGNANCY. 

only  suitable  in  a  treatise  on  Embryology.  It  is  of  importance,  how- 
ever, that  the  practitioner  should  have  it  in  his  power  to  determine 
approximately  the  age  of  the  foetus  in  abortions  or  premature  labor, 
and  for  this  purpose  it  is  necessary  to  describe  briefly  the  appear- 
ance of  the  foetus  at  various  stages  of  its  growth. 

1st  Month. — The  foetus  in  the  first  month  of  gestation  is  a  minute 
gelatinous,  and  semi-transparent  mass,  of  a  grayish  color,  in  which 
no  definite  structure  can  be  made  out,  and  in  which  no  head  nor  ex- 
tremities can  be  seen.  It  is  rarely  to  be  detected  in  abortions,  being 
lost  in  surrounding  blood  clots.  In  the  few  examples  which  have 
been  carefully  examined  it  did  not  measure  more  than  a  line  in  length. 
It  is,  however,  already  surrounded  by  the  amnion,  and  the  pedicle 
of  the  umbilical  vesicle  can  be  traced  into  the  unclosed  abdominal 
cavity. 

2d  Month. — The  embrj'^o  becomes  more  distinctly  apparent,  and  is 
curved  on  itself,  weighing  about  62  grains,  and  measuring  6  to  8 
lines  in  length.  The  head  and  extremities  are  distinctly  visible — ■ 
the  latter  in  the  form  of  rudimentary  projections  from  the  body. 
The  eyes  are  to  be  seen  as  small  black  spots  on  the  side  of  the  head. 
The  spinal  column  is  divided  into  separate  vertebrae.  The  indepen- 
dent circulatory  system  of  the  foetus  is  now  beginning  to  form,  the 
heart  consisting  of  only  one  ventricle  and  one  auricle,  from  the 
former  of  which  both  the  aorta  and  pulmonary  arteries  arise.  On 
either  side  of  the  vertebral  column,  reaching  from  the  heart  to  the 
pelvis,  are  two  large  glandular  structures,  the  corpora  Wolffiam'a, 
which  consists  of  a  series  of  convoluted  tubes  opening  into  an  excre- 
tory duct,  running  along  their  external  borders,  and  connected  below 
with  the  common  cloaca  of  the  genito-urinary  and  digestive  tracts. 
They  seem  to  act  as  secreting  glands,  and  fulfil  the  functions  of  the 
kidneys  before  these  are  formed.  Towards  the  end  of  the  second 
month  they  atrophy  and  disappear,  and  the  only  trace  of  them  in 
the  foetus  at  term  is  to  be  found  in  the  parovarium  lying  between 
the  folds  of  the  broad  ligaments.  At  this  stage  of  development 
there  are  met  with  in  the  human  embryo,  as  in  that  of  all  mammals, 
four  transverse  fissures  opening  into  the  pharynx,  which  are  analo- 
gous to  the  permanent  branchiae  of  fishes.  Their  vascular  supply  is 
also  similar,  as  the  aorta  at  this  time  gives  off  four  branches  on  each 
side,  each  of  which  forms  a  branchial  arch,  and  these  afterwards 
unite  to  form  the  descending  aorta.  By  the  end  of  the  sixth  Aveek 
these,  as  well  as  the  transverse  fissures  to  which  they  are  distributed, 
disappear.  By  the  end  of  the  second  month  the  kidneys  and  supra- 
renal capsules  are  forming,  and  the  single  ventricle  is  divided  into 
two  by  the  growth  of  the  inter-ventricular  septum.  The  umbilical 
cord  is  quite  straight,  and  is  inserted  into  the  lower  ];)art  of  the  ab- 
domen. Centres  of  ossification  are  showing  themselves  in  the  infe- 
rior maxillary  bones  and  the  clavicle. 

Sd  Month. — The  embryo  weighs  from  70  to  300  grains,  and  meas- 
ures from  2|  to  3J  inches  in  length.  The  forearm  is  well  formed 
and  the  first  traces  of  the  fingers  can  be  made  out.  The  head  is 
large  in  proportion  to  the  rest  of  the  body,  and  the  eyes  are  promi- 


ANATOMY    AND    PHYSIOLOGY    OF    THE    FOETUS.  Ill 

nent.  The  umbilical  vesicle  and  allantois  have  disappeared,  the 
greater  portion  of  the  chorion  villi  have  atrophied,  and  the  placenta 
is  distinctly  formed. 

4:th  Month. — The  weight  is  from  4  to  6  oz.,  and  the  length  about  6 
inches.  The  convolutions  of  the  brain  are  beginning  to  develop. 
The  sex  of  the  child  can  now  be  ascertained  on  inspection.  The 
muscles  are  sufficiently  formed  to  produce  distinct  movements  of  the 
limbs.  Ossification  is  extending,  and  can  be  traced  in  the  occipital 
and  frontal  bones,  and  in  the  mastoid  processes.  The  sexual  organs 
are  differentiated. 

bth  Month. — AVeight  about  10  oz.  Length,  9  or  10  inches.  Hair 
is  observed  covering  the  head,  which  forms  about  one-third  of  the 
length  of  the  whole  foetus.  The  nails  are  beginning  to  form,  and 
ossification  has  commenced  in  the  ischium. 

6th  Mmth. —Weight  about  1  lb.  Length,  11  to  12  J  inches.  The 
hair  is  darker.  The  eyelids  are  closed,  and  the  membrana  pupillaris 
exists ;  eyelashes  have  now  been  formed.  Some  fat  is  deposited 
under  the  skin..  The  testicles  are  still  in  the  abdominal  cavity.  The 
clitoris  is  prominent.     The  pubic  bones  have  begun  to  ossify. 

7th  Month. — Weight,  from  3  to  -1  lbs.  Length,  13  to  15  inches. 
The  skin  is  covered  with  unctuous,  sebaceous  matter,  and  there  is  a 
more  considerable  deposit  of  subcutaneous  fat.  The  eyelids  are  open. 
The  testicles  have  descended  into  the  scrotum. 

8/!/;.  Month. — AYeight,  from  4  to  5  lbs.  Length,  16  to  18  inches, 
and  the  foetus  seems  now  to  grow  in  thickness  rather  than  in  length. 
The  nails  are  completely  developed.  The  membrana  pupillaris  has 
disappeared. 

Fcetxis  at  Term. — At  the  completion  of  pregnancy  the  foetus  weighs 
on  an  average  Q\  lbs.,  and  measures  about  20  inches  in  lengtli.  These 
averages  are,  however,  liable  to  great  variation.  Eemarkable  his- 
tories are  given  by  many  writers  of  foetuses  of  extraordinary  weight, 
which  have  been  probably  greatly  exaggerated.  Out  of  3000  chil- 
dren delivered  under  the  care  of  Cazeaux  at  various  charities,  one 
only  weighed  10  lbs.  There  are,  however,  several  carefully  recorded 
instances  of  weight  far  exceeding  this  ;  but  they  are  undoubtedly- 
much  more  uncommon  than  is  generally  supposed.  Dr.  Eamsbotham 
mentions  a  foetus  weighing  16J  lbs.,  Cazeaux  tells  of  one  which 
he  delivered  by  turning  which  weighed  18  lbs.,  and  measured  2  feet 
IJ  inches,  and  the  birth  of  one  weighing  21  lbs.  has  been  recently  re- 
corded.^ Such  overgrown  children  are  almost  invariably  stillborn. 
On  the  other  hand,  mature  children  have  been  born  and  survived 
which  have  not  weighed  more  than  5  lbs. 

[Probably  the  largest  foetus  on  record  was  that  of  Mrs.  Captain 
Bates,  the  ISTova  Scotia  giantess,  a  woman  of  7  ft.  9  in.,  whose  husband 
is  also  of  gigantic  build,  reaching  7ft.  7  in.  in  height.  This  child, 
born  in  Ohio,  was  their  second,  and  Avaslost  in  its  birth,  as  no  forceps 
could  be  procured  of  sufficient  size  to  grasp  the  head.  The  foetus 
weighed  23|-  lbs.,  and  was  30  in.  in  length.    Their  first  infant  weighed 

J  Brit.  Med.  Jonrn.  Feb.  1,  1879. 


112  PREGNANCY. 

19  lbs.  We  have  had  children  born  in  this  city  at  maturity  and  live, 
that  weighed  but  one  pound.  The  well-remembered  "  Pincus  babv" 
weighed  a  pound  and  an  ounce.^ — Ed.J 

The  average  size  of  male  children  at  birth,  as  in  afterlife,  is  some- 
what greater  than  that  of  female.  Thus  Simpson^  found  that  out  of 
100  cases  the  male  children  averaged  10  oz.  more  in  weight  than  the 
female,  and  J  an  inch  more  in  length.  A  new-born  child  at  term  is 
generally  covered  to  a  greater  or  less  extent  with  a  greasy,  nnctuous 
material,  the  vernix  caseosa,  which  is  formed  of  epithelial  scales  and 
the  secretion  of  the  sebi^ceous  glands,  and  which  is  said  to  be  of  use 
in  labor,  by  lubricating  the  surface  of  the  child.  The  head  is  gene- 
rally covered  with  long  dark  hair,  which  frequently  falls  off  or  changes 
in  color  shortly  after  birth.  Dr.  Wiltshire^  has'  called  attention  to 
an  old  observation,  that  the  eyes  of  all  new-born  children  are  of  a 
peculiar  dark  steel-gray  color,  and  that  they  do  not  acquire  their 
permanent  tint  until  some  time  after  birth.  The  umbilical  cord  is 
generally  inserted  below  the  centre  of  the  body. 

Anatomy  of  the  Foetal  Head. — The  most  important  part  of  the  foetus 
from  an  obstetrical  point  of  view  is  the  head,  which  requires  a  sepa- 
rate study,  as  it  is  the  usual  presenting  part,  and  the  facility  of  the 
labor  depends  on  its  accurate  adaptation  to  the  maternal  passages. 

The  chief  anatomical  peculiarity  of  interest,  in  the  head  of  the 
foetus  at  term,  is  that  the  bones  of  the  skull,  especially  of  its  vertex 
■ — -which,  in  the  vast  majority  of  cases,  has  to  pass  first  through  the 
pelvis — are  not  firmly  ossified  as  in  adult  life,  but  are  joined  loosely 
together  by  membrane  or  cartilage.  The  result  of  this  is,  that  the 
skull  is  capable  of  being  moulded  and  altered  in  form  to  a  very  con- 
siderable extent  by  the  pressure  to  which  it  is  subjected,  and  thus  its 
passage  through  the  pelvis  is  very  greatly  facilitated.  This,  how- 
ever, is  chiefly  the  case  with  the  cranium  proper,  the  bones  of  the 
face  and  of  the  base  of  the  skull  being  more  firmly  united.  By  this 
means  the  delicate  structures  at  the  base  of  the  brain  are  protected 
from  pressure,  Avhile  the  change  of  form  which  the  skull  undergoes 
during  labor  implicates  a  portion  of  the  skull  where  pressure  on  the 
cranial  contents  is  least  likely  to  be  injurious. 

The  divisions  between  the  bones  of  the  cranium  are  further  of  ob- 
stetric importance  in  enabling  us  to  detect  the  precise  position  of  the 
head  during  labor,  and  an  accurate  knowledge  of  them  is  therefore 
essential  to  the  obstetrician. 

The  Sutures  and  Fontanelles. — We  talk  of  them  as  sutures  and 
fontanelles^  the  former  being  the  lines  of  junction  betAveen  the  sepa- 
rate bones  Avhich  overlap  each  other  to  a  greater  or  less  extent  during 
labor  ;  the  latter  membranous  interspaces  where  the  sutures  join  each 
other. 

The  principal  sutures  are:  1st.  The  sagittal.,  which  separates  the 
two  parietal  bones,  and  extends  longitudinally  backwards  along  the 
vertex  of  the  head.     2d.  The  frontal^  which  is  a  continuation  of  the 

'   [II  was  remarkable  for  the  strength  of  its  cry.] 

2  Selected  Obst.  Works,  p.  327.  *      ^  Lancet,  February  11,  1871. 


ANATOMY    AND    PHYSIOLOGY    OF    THE    F(ETUS. 


113 


sagittal,  and  divides  the  two  halves  of  tlie  frontal  bone,  at  this  time 
separate  from  each  otiier.  8d.  The  coronal^  which  separates  the 
frontal  from  the  parietal  bones,  and  extends  from  the  squamous  por- 
tion of  the  temporal  bone  across  the  head  to  a  corresponding  point 
on  the  opposite  side ;  and  4th,  the  larahdoidul^  which  receives  its 
name  from  its  resemblance  to  the  Greek  letter  a,  and  separates  the 
occipital  from  the  parietal  bones  on  either  side.-  The  fontanelles 
(Fig.  61)  are  the  membranous  interspaces  where  the  sutures  join — 
the  anterior  and  larger  being  lozenge-shaped,  and  formed  by  the  junc- 
tion of  the  frontal,  sagittal,  and  two  halves  of  the  coronal  sutures. 
It  will  be  well  to  note  that  there  are,  therefore,  four  lines  of  sutures 
running  into  it,  and  four  angles,  of  which   the  anterior,  formed  by 


Fig.  61. 


Fig.  62. 


Anterior  and  Posterior  Fontanelle'^. 


Bi-parictal  Diameter,  Sagittal  or   Lambdoidal 
Sutures,  with  Posterior  Fontanelles. 


the  frontal  suture,  is  most  elongated  and  well  marked.  The  posterior 
ftmtanelle  (Fig.  62)  is  formed  by  the  junction  of  the  sagittal  suture 
with  the  two  legs  of  the  lambdoidal.  It  is,  therefore,  triangular  in 
shape,  with  three  lines  of  suture  entering  it  in  three  angles,  and  is 
much  smaller  than  the  anterior  fontanelle,  forming  merely  a  depres- 
sion into  which  the  tip  of  the  finger  can  be  placed,  while  the  latter  is 
a  hollow  as  big  as  a  shilling,  or  even  larger.  As  it  is  the  posterior 
fontanelle  which  is  generally  lowest,  and  the  one  most  commonly  felt 
during  labor,  it  is  important  for  the  student  to  familiarize  himself 
with  it,  and  he  should  lose  no  opportunity  of  studying  the  sensations 
imparted  to  the  finger  by  the  sutures  and  fontanelles  in  the  head  of 
the  child  after  birth. 

The  Diameter  of  the  Foetal  Skull. — For  the  purpose  of  understand- 
ing the  mechanism  of  labor,  we  must  study  the  measurements  of  the 
foetal  head  in  relation  to  the  cavity  through  which  it  has  to  pass. 
They  are  taken  from  corresponding  points  opposite  to  each  other, 
and  are  known  as  the  diameters  of  the  skull  (Fig.  63).  Those  of 
most  importance  are:  1st.  The  occijnto-me^ital,  from  the  occipital 
protuberance  to  the  point  of  the  chin,  5.25"  to  5.50".  2d.  The  occi- 
pito-frontalj  from  the  occiput  to  the  centre  of  the  forehead,  4.50"  to 


lU 


PREGNANCY. 


Fig.  63. 


1  &  2.  Occipitofrontal  diameter. 
3  &  4.  Occipitomental. 
5  &  6.  Cervico-bregmalic. 
7  &  8.  Fronto-mental. 


b".  3cl.  The  suh-oca'pito-hregmatic 
from  a  point  midway  between  tlie 
occipital  protuberance  and  the 
margin  of  the  foramen  magnum 
to  the  centre  of  the  anterior 
fontanelle,  3.25".  4th.  The  cer- 
vico-hregniatic^  from  the  anterior 
margin  of  the  foramen  magnum 
to  the  centre  of  the  anterior  fon- 
tanelle, 8.75".  5th,  Transverse  or 
hi-parietcd^  between  the  parietal 
protuberances,  3.75"  to  4".  6th. 
Bi-temjooral,  between  the  ears, 
Fronto-mental,  from 
the  forehead  to  the 


.50".     7th. 

the  apex  of 

chin,  3.25". 

Alteration  of  Diameter  during 
Lahor. — The  length  of  these  respective  diameters,  as  given  by  differ- 
ent writers,  differs  considerably — a  fact  to  be  explained  by  the  meas- 
urements having  been  taken  at  different  times;  by  some  just  after 
birth,  when  the  head  was  altered  in  shape  by  moulding  it  had  under- 
gone ;  by  others  when  this  had  either  been  slight,  or  after  the  head 
had  recovered  its  normal  shape.  The  above  measurements  may  be 
taken  as  the  average  of  those  of  the  normally  shaped  head,  and  is  to 
be  noted  that  the  first  two  are  most  apt  to  be  modified  during  labor. 
The  amount  of  compression  and  moulding  to  which  the  head  may 
be  subjected,  without  proving  fatal  to  the  foetus,  is  not  certainly 
known,  but  it  is  doubtless  very  considerable.  Some  interesting  ex- 
amples of  the  extent  to  which  the  head  may  be  altered  in  shape  m 
difficult  labors  have  been  given  by  Barnes,^  who  has  shown  by  trac- 
ings of  the  shape  of  the  head  taken  immediately  after  delivery,  that 
in  protracted  labor  the  occipito-mental  and  occipito-frontal  diameters 
may  be  increased  more  than  an  inch  in  length,  while  lateral  compres- 
sion may  diminish  the  bi-parietal  diameter  to  the  same  length  as  the 
inter-auricular.  The  foetal  head  is  movable  on  the  vertical  column 
to  the  extent  of  a  quarter  of  a  circle  ;  and  it  seems  probable  that  the 
laxity  of  the  ligaments  admits  with  impunity  a  greater  circular  move- 
ment than  would  be  possible  in  the  adult. 

Influence  of  Sex  and  Race  on  the  Foetal  Head.— On  taking  the  ave- 
rage of  a  large  number  of  measurements,  it  is  found  that  the  heads 
of  male  children  are  larger  and  more  firmly  ossified  than  those  of 
females,  the  former  averao-ins;  about  half  an  inch  more  in  circum- 
ference.  Sir  James  Simpson  attributed  great  importance  to  this  fact, 
and^believed  that  it  was  sufficient  to  account  for  the  larger  proportion 
of  still-births  in  male  than  in  female  children,  as  well  as  for  the  greater 
difficulty  of  labor  and  the  increased  maternal  mortality  that  are  found 
to  attend  on  male  births.  His  well-known  paper  on  this  subject, 
which  has  given  rise  to  much  controversy,  is  full  of  the  most  elaborate 


1    Obst.  Trans.,  vol    vii. 


ANATOMY    AND    PHYSIOLOGY    OF    THE    FCETUS.  115 

details,  and  so  great  did  he  believe  the  foetal  influence  to  be,  that  he 
calculated  that  between  the  years  1834  and  1837  there  were  lost  in 
Great  Britain,  as  a  consequence  of  the  slightly  larger  size  of  the  male 
than  of  the  female  head  at  birth,  about  50,000  lives,  including  those 
of  about  40,000  or  47,000  infants,  and  of  between  3000  and  4000 
mothers  who  died  in  childbed.^  It  is  probable  that  race  and  other 
conditions,  such  as  civilization  and  Intellectual  culture,  have  con- 
siderable influence  on  the  size  of  the  foetal  skull,  but  we  are  not  in 
possession  of  sufficiently  accurate  data  to  justify  any  very  positive 
opinion  on  these  points. 

Position  of  the  Foetus  in  Utero. — In  the  very  large  majority  of  cases 
the  foetus  lies  in  utero  with  the  head  downwards,  and  is  so  placed  as 
to  be  adapted  in  the  most  convenient  way  to  the  cavity  in  which  it 
is  placed.  The  uterine  cavity  is  most  roomy  at  the  fundus,  and 
narrowest  at  the  cervix,  and  the  greatest  bulk  of  the  foetus  is  at  the 
breech,  so  that  the  largest  part  of  the  child  usually  lies  in  the  part 
of  the  uterus  best  adapted  to  contain  it.  The  various  parts  of  the 
child's  body  are  further  so  placed,  in  regard  to  each  other,  as  to  take 
up  the  least  possible  amount  of  space.  (See  frontispiece.)  The  body 
is  bent  so  that  the  spine  is  curved  with  its  convexity  outwards,  this 
curvature  existing  from  the  earliest  period  of  development ;  the  chin 
is  flexed  on  the  sternum  ;  the  forearms  are  flexed  on  the  arms,  and 
lie  close  together  on  the  front  of  the  chest ;  the  legs  are  flexed  on 
the  thighs,  and  the  thighs  drawn  up  on  the  abdomen ;  the  feet  are 
drawn  up  towards  the  legs ;  the  umbilical  cord  is  generall}^  placed 
out  of  reach  of  injurious  pressure,  in  the  space  between  the  arms 
and  the  thighs.  Variations  from  this  attitude,  however,  are  not 
uncommon,  and  are  not,  as  a  rule,  of  much  consequence.  Although 
the  cranial  presentations  are  much  the  most  common,  averaging  96 
out  of  every  100  cases,  other  presentations  are  by  no  means  rare,  the 
next  most  frequent  being  either  that  of  the  breech,  in  which  the  long 
diameter  of  the  child  lies  in  the  long  diameter  of  the  uterine  cavity, 
or  some  variety  of  transverse  presentation,  in  which  the  long  diam- 
eter of  the  foetus  lies  obliquely  across  the  uterus,  and  no  longer 
corresponds  to  its  longitudinal  axis. 

Changes  of  Foetal  Position  during  Pregnancy. — -It  was  long  bslieved 
that  the  head  presentation  was  only  assumed  towards  the  end  of 
pregnancy,  when  it  was  supposed  to  be  produced  by  a  sudden  move- 
ment on  the  part  of  the  foetus,  known  as  the  culhute.  It  is  now  well 
known  that,  in  the  large  majority  of  cases,  the  head  is- lowest  during 
all  the  latter  part  of  pregnancy,  although  changes  in  position  are 
more  common  than  is  generally  believed  to  be  the  case,  and  presen- 
tation of  y,)arts  other  than  the  head  is  much  more  frequent  in  pre- 
mature labor  than  in  delivery  at  term.  In  evidence  of  the  last 
statement,  Churchill  says  that  in  labor  at  the  seventh  month  the 
head  presents  only  83  times  out  of  100  when  the  child  is  living,  and 
that  as  many  as  63  per  cent,  of  the  presentations  are  preternatural 
when  the  child  is  still-born.     The  frequency  with  which  the  foetus 

1  Selected  Obstet.  Works,  p.  363. 


116 


PREGNANCY, 


changes  its  position  before  delivery  has  been  made  the  subject  of 
investigation  by  various  German  obstetricians,  and  the  fact  can  be 
readily  ascertained  by  examination.  Yalenta^  found  that  out  of 
nearly  1000  cases,  carefully  and  frequently  examined  by  him,  in  57.6 
per  cent,  the  presentation  underwent  no  change  in  the  latter  months 
of  pregnancy,  but  in  the  remaining  42.4  per  cent,  a  change  could  be 
readily  detected.  These  alterations  were  found  to  be  most  frequent 
in  multiparte,  and  the  tenden-cy  was  for  abnormal  presentations  to 
alter  into  normal  ones.  Thus  it  Avas  common  for  transverse  presenta- 
tions to  alter  longitudinally,  and  but  rare  for  breech  presentations  to 
change  into  head.  The  ease  with  which  these  changes  are  effected 
no  doubt  depends,  in  a  considerable  degree,  on  the  laxity  of  the 
uterine  parietes,  and  on  the  greater  quantity  of  amniotic  fluid,  by 
both  of  which  the  free  mobility  of  the  foetus  is  favored. 

Detection  of  Foetal  Position  hy  Abdominal  Palpation. — The  facilitv 
with  which  the  position  of  the  foetus  in  utero  can  be  ascertained  by 
abdominal  palpation  has  not  been  generally  appreciated  in  obstetric 
works,  and  yet,  by  a  little  practi.ce,  it  is  easy  to  make  it  out.  Much 
information  of  importance  can  be  gained  in  this  way,  and  it  is  quite 
possible,  under  favorable  circumstances,  to  alter  abnormal  presen- 
tations before  labor  has  begun.     For  the  purpose  of  making  this 

Fig.  64. 


Mode  of  ascertaining  the  Position  of  the  Foetus  hy  Palpation. 

examination,  the  patient  should  lie  at  the  edge  of  the  bed,  with  her 
shoulders  slightly  raised,  and  the  abdomen  uncovered.  The  first 
observation  to  make  is  to  see  if  the  longitudinal  axis  of  the  uterine 
tumor  corresponds  with  that  of  the  mother's  abdomen  ;  if  it  does,  the 
presentation  must  be  either  a  head  or  a  breech.  By  spreading  the 
hands  over  the  uterus  (Fig.  64),  a  greater  sense  of  resistance  can  be 


3  Mon.  f.  Geburt,,  1866. 


ANATOMY    AND    PHYSIOLOGY    OF    THE    FCETUS  117 

felt,  in  most  cases,  on  one  side  than  on  the  other,  corresponding  to 
the  back  of  the  child.  By  striking  the  tips  of  the  fingers  suddenly 
inwards  at  the  fundus,  the  hard  breech  can  generally  be  made  out, 
or  the  head,  still  more  easily,  if  the  breech  be  downwards.  When 
the  uterine  walls  are  unusually  lax,  it  is  often  possible  to  feel  the 
limbs  of  the  child.  These  observations  can  be  generally  corroborated 
by  auscultation,  for  in  head  presentations  the  foetal  heart  can  usually 
be  heard  below  the  umbilicus,  and  in  breech  cases  above  it.  Trans- 
verse presentations  can  even  more  easily  be  made  out  by  abdominal 
palpation.  Here  the  long  axis  of  the  uterine  tumor  does  not  corre- 
spond with  the  long  axis  of  the  mother's  abdomen,  but  lies  obliquely 
across  it.  By  palpation  the  rounded  mass  of  the  head  can  be  ea.sily 
felt  in  one  of  the  mother's  flanks,  and  the  breech  in  the  other,  while 
the  foetal  heart  is  heard  pulsating  nearer  to  the  side  at  which  the 
head  is  detected. 

Explanation  of  the  Position  of  the  Foetus  in  TJtero. — The  reason  why 
the  head  presents  so  frequently  has  been  made  the  subject  of  much 
discussion.  The  oldest  theory  was,  that  the  head  lay  over  the  os 
uteri  as  the  result  of  gravitation,  and  the  influence  of  gravity,  although 
contested  by  many  obstetricians,  prominent  among  whom  were  Du- 
bois and  Simpson,  has  been  insisted  upon  as  the  chief  cause  by  others, 
Dr.  Duncan  being  one  of  the  most  strenuous  advocates  of  this  view. 
The  objections  urged  against  the  gravitation  theory  were  drawn 
partly  from  the  result  of  experiments,  and  partly  from  the  frequency 
with  which  abnormal  presentations  occurred  in  premature  labors, 
when  the  action  of  gravity  could  not  be  supposed  to  be  suspended. 
The  experiments  made  by  Dubois  went  to  show  that  when  a  foetus 
was  suspended  in  water  gravitation  caused  the  shoulders,  and  not 
the  head  to  fall  lowest.  He,  therefore,  advanced  the  hypothesis  that 
the  position  of  the  foetus  was  due  to  instinctive  movements,  which  it 
made  to  adapt  itself  to  the  most  comfortable  position  in  which  it 
could  lie.  It  need  only  be  remarked  that  there  is  not  the  slightest 
evidence  of  the  foetus  possessing  any  such  poAver.  Simpson  proposed  a 
theory  which  was  much  more  plausible.  He  assumed  that  the  foetal 
position  was  due  to  reflex  movements  produced  by  physical  irrita- 
tions to  which  the  cutaneous  surface  of  the  foetus  is  subjected  from 
changes  .of  the  mother's  position,  uterine  contractions,  and  the  like. 
The  absence  of  these  movements,  in  the  case  of  the  death  of  the  foetus, 
would  readily  explain  the  frequency  of  mal-presentation  under  such 
circumstances.  The  obvious  objection  to  this  theory,  complete  as  it 
seems  to  be,  is  the  absence  of  any  proof  that  such  constant  extensive 
reflex  movements  really  do  occur  in  utero.  Dr.  Duncan  has  very 
conclusively  disposed  of  the  principal  objections  which  have  been 
raised  against  the  influence  of  gravitation,  and  when  an  obvious  ex- 
planation of  so  simple  a  kind  exists,  it  seems  useless  to  seek  further 
for  another.  He  has  shown  that  Dubois's  experiments  did  not  accu- 
rately represent  the  state  of  the  foetus  in  utero,  and  that  during  the 
greater  part  of  the  day,  when  the  woman  is  upright,  or  lying  on  her 
back,  the  foetus  lies  obliquely  to  the  horizon  at  an  angle  of  about  30°. 
The  child  thus  lies,  in  the  former  case,  on  an  inclined  plane,  formed 


118 


PKEGNANCr, 


hy  tlie  anterior  uterine  wall  and  by  the  abdominal  parietes,  in  the 
latter  by  the  posterior  uterine  wall  and  the  vertebral  column.  Down 
the  inclined  plane  so  formed  the  force  of  gravity  causes  the  foetus 
to  slide,  and  it  is  only  when  the  woman  lies  on  her  side  that  the 
foetus  is  placed  horizontally,  and  is  not  subjected  iu  the  same  degree 
to  the  action  of  gravity  (Fig.  65).     The  frequency  of  mal-presenta- 


Diagrain  illustrating  the  Effect  of  Gravity  on  the  Poetus.     (After  Duncan  ) 

a,  b,  is  parallel  to  the  axis  of  the  pregnant  litems  and  pelvic  brim,    e,  d,  e,  is  a  perpendicular  line. 

e,  the  centre  of  gravity  of  the  foetus,    d,  the  centre  of  flotation. 

tions  in  premature  labors  is  explained  by  Dr.  Duncan  partly  by  the 
fact  that  the  death  of  the  child  (which  so  frequently  precedes  such 

Fig.  66. 


Illustrating  the  greater  Mobility  of  the  Footus  and  the  Larger  relative  Amount  of  Liquor  Aninil  in 

Early  Pregnancy.     (After  Duncan.) 

a,b.  J^xis  of  pregnant  uterus.  b,  7i.  A  horizontal  line. 

cases)  alters  its  centre  of  gravity,  and  partly  by  the  greater  mobil- 
ity of  the  child  and  the  greater  relative  amount  of  liquor  amnii 
(Fig.  66).     The  influence  of  gravitation  is  probably  greatly  assisted 


ANATOMY    AND    PHYSIOLOGY    OF    THE    FCETUS.  119 

by  tlie  contractions  of  tlic  uterus  "vvhicli  are  going  on  during  the 
greater  part  of  pregnancy.  Tiie  influence  of  tiiese  was  pointed  out 
by  Dr.  Tyler  Smith,  who  distinctly  .showed  that  the  contractions  of 
the  uterus  preceding  delivery  exerted  a  moulding  or  adapting  influ- 
ence on  the  foetus,  and  prevented  undue  alterations  of  its  position. 
Dr.  Hicks  proved^  that  these  uterine  contractions  are  of  constant 
occurrence  from  the  earliest  period  of  pregnancy,  and  there  can  be 
little  doubt  that  they  must  have  an  important  influence  on  the  body 
contained  within  the  uterus.  The  whole  subject  has  been  recently 
considered  by  Pinard^  who  shows  that  many  factors  are  in  action  to 
produce  and  maintain  the  usual  position  of  the  foetus  in  utero,  Avhich 
may  be  either  of  an  active  or  a  passive  character :  the  former  being 
chiefly  the  active  movements  of  the  foetus  and  the  contractions  of  the 
litems  and  the  abdominal  muscles ;  the  latter,  the  form  of  the  uterus 
and  the  foetus,  the  slippery  surface  of  the  amnion,  pressure  of  the 
amniotic  fluid,  etc.  When  any  of  these  factors  are  at  fault,  mal-pre- 
sentation  is  apt  to  occur. 

Fnnctions  of  the  Foztiis. — -The  functions  of  the  foetus  are  in  the 
main  the  same,  with  differences  depending  on  the  situation  in  which 
it  is  placed,  as  those  of  the  separate  being.  It  breathes,  it  is 
nourished,  it  forms  secretions,  and  its  nervous  sj^stem  acts.  The 
mode  in  which  some  of  these  functions  are  carried  on  in  intra-uterine 
life  requires  separate  consideration. 

1.  Nutrition. — -During  the  early  period  of  pregnancy,  and  before 
the  formation  of  the  umbilical  vesicle  and  the  allantois,  it  is  certain 
that  nutritive  material  must  be  supplied  to  the  ovum  by  endosmosis 
through  its  external  envelope.  The  precise  source,  however,  from 
which  this  is  obtained  is  not  positively  known.  By  some  it  is 
believed  to  be  derived  from  the  granulations  of  the  discus  proligerus 
which  surround  it  as  it  escapes  from  the  Graafian  follicle,  and  sub- 
sequently from  the  layer  of  albuminous  matter  which  surrounds  the 
ovum  before  it  reaches  the  uterus ;  while  others  think  it  probable 
that  it  may  come  from  a  special  liquid  secreted  by  the  interior  of 
the  Fallopian  tube  as  the  ovum  passes  along  it.  As  soon  as  the 
ovum  has  reached  the  uterus,  there  is  every  reason  to  believe  that 
the  umbilical  vesicle  is  the  chief  source  of  nourishment  to  the  embryo, 
through  the  channel  of  the  omphalo-mesenteric  vessels,  which  convey 
matters  absorbed  from  the  interior  of  the  vesicle  to  the  intestinal 
canal  of  the  foetus.  At  this  time  the  exterior  of  the  ovum  is  covered 
by  the  numerous  fine  villosities  of  the  primitive  chorion,  which  are 
imbedded  in  the  mucous  membrane  of  the  uterus,  and  it  is  thought 
that  they  may  absorb  materials  from  the  maternal  system,  which  may 
be  either  directly  absorbed  by  the  embryo,  or  which  may  serve  the 
purpose  of  replacing  the  nutritive  matter  which  has  been  removed 
from  the  umbilical  vesicle  by  the  omphalo-mesenteric  vessels.  This 
point  it  is,  of  course,  impossible  to  decide.  Joulin,  however,  thinks 
that  these  villi  probably  have  no  direct  influence  on  the  nourishment 

'  Obst.  Trans,  vol.  xiii.  p.  216. 

2  Annal.  de  Gyn.,  May  and  July,  1878. 


120  PREGNANCY. 

of  the  foetus,  wliicli  is  at  this  time  solely  effected  by  the  umbilical 
vesicle,  bat  that  they  absorb  fluid  from  the  maternal  system,  which 
passes  through  the  amnion  and  forms  the  liquor  amnii.  As  soon  as 
the  allantois  is  developed,  vascular  communication  between  the  fcetus 
and  the  maternal  structures  is  established,  and  the  temporary  func 
tion  of  the  umbilical  vesicle  is  over;  that  structure,  therefore,  rapidly 
atrophies  and  disappears,  and  the  nutrition  of  the  foetus  is  now  solely 
carried  on  by  means  of  the  chorion  villi,  lined  as  they  now  are  bv 
the  vascular  endo-chorion,  and  chiefly  by  those  which  go  to  form  the 
substance  of  the  placenta. 

This  statement  is  opposed  to  the  views  of  many  physiologists,  who 
believe  that  a  certain  amount  of  nutritive  material  is  conveyed  to 
the  foetus  through  the  channel  of  the  liquor  amnii,  itself  derived 
from  the  maternal  system,  which  is  supposed  either  to  be  absorbed 
through  the  cutaneous  surface  of  the  foetus,  or  carried  to  the  intesti- 
nal canal  by  deglutition.  The  reasons  for  assigning  to  the  liquor 
amnii  a  nutritive  function  are,  however,  so  slight,  that  it  is  difficult 
to  believe  that  it  has  any  appreciable  action  in  this  way.  They  are 
based  on  some  questionable  observations,  such  as  those  of  Weydlich, 
who  kept  a  calf  alive  for  fifteen  days  by  feeding  it  solely  on  liquor 
amnii,  and  the  experiments  of  Burdach,  who  found  the  cutaneous 
lymphatics  engorged  in  a  foetus  removed  from  the  amniotic  cavity, 
while  those  of  the  intestine  were  empty.  The  deglutition  of  the 
liquor  amnii  for  the  purposes  of  nutrition,  has  been  assumed  from  its 
occasional  detection  in  the  stomach  of  the  foetus,  the  presence  of 
which  may,  however,  be  readily  explained  by  spasmodic  efforts  at 
respiration,  which  the  foetus  undoubtedly  often  makes  before  birth, 
especially  when  the  placental  circulation  is  in  any  way  interfered 
with,  and  during  which  a  certain  quantity  of  fluid  would  necessarily 
be  swallowed.  The  quantity  of  nutritive  material,  however,  in  the 
liquor  amnii  is  so  small — not  more  than  6  to  9  parts  of  albumen  in 
1000 — -that  it  is  impossible  to  conceive  how  it  could  have  any  appre- 
ciable influence  in  nutrition,  even  if  its  absorption,  either  by  the  skin 
or  stomach,  were  susceptible  of  proof. 

That  the  nutrition  of  the  foetus  is  effected  through  the  placenta 
is  proved  by  the  common  observation  that  whenever  the  placental 
circulation  is  arrested,  as  by  disease  of  its  structure,  the  foetus  atro- 
phies and  dies.  The  precise  mode,  hoAvever,  in  which  nutritive 
materials  are  absorbed  from  the  maternal  blood  is  still  a  matter  of 
doubt,  and  must  remain  so  until  the  mooted  points  as  to  the  minute 
anatomy  of  the  placenta  are  settled.  The  various  theories  enter- 
tained on  this  subject  by  the  upholders  of  the  Hunterian  doctrine  of 
placental  anatomy,  and  by  those  who  den}^  the  existence  of  a  sinus 
system,  have  already  been  referred  to  in  the  chapter  on  the  Anatomy 
of  the  Placenta,  to  which  the  reader  is  referred  (pp.  106-108). 

2.  Respiration. — One  of  the  chief  functions  of  the  placenta,  besides 
that  of  nutrition,  is  the  supply  of  oxygenated  blood  to  the  foetus. 
That  this  is  essential  to  the  vitality  of  the  foetus,  and  that  the  pla- 
centa is  the  site  of  oxygenation,  are  shown  by  the  facts  that  when- 
•ever  the  placenta  is  separated,  or  the  access  of  foetal  blood   to  it 


ANATOMY"    AND    PHYSIOLOGY    OF    THE    FCETUS.  121 

arrested  oy  compression  of  the  cord,  instinctive  attempts  at  inspira- 
tion are  made,  and  if  aerial  respiration  cannot  be  performed,  the  foetus 
is  expelled  asphyxiated.  Like  the  other  functions  of  the  foetus  during 
intra- uterine  life,  that  of  respiration  has  been  made  the  subject  of 
numerous  more  or  less  ingenious  hypotheses.  Thus  many  have 
believed  that  the  foetus  absorbed  gaseous  material  from  the  liquor 
amnii,  which  served  the  purpose  of  oxygenating  its  blood,  St,  Hilaire 
thinking  that  this  Avas  affected  by  minute  openings  in  its  skin, 
Beclard  and  others  through  the  bronchi,  to  which  they  believed  the 
liquor  amnii  gained  access.  Independently  of  the  entire  want  of 
evidence  of  the  absorption  of  gaseous  materials  by  these  channels, 
the  theory  is  disproved  by  the  fact  that  the  liquor  amnii  contains  no 
air  which  is  capable  of  respiration.  Serrcs  attributed  a  similar  func- 
tion to  some  of  the  chorion  villi,  which  he  believed  penetrated  the 
utricular  glands  of  the  decidua  reflexa,  and  absorbed  gas  from  the 
hydroperione,  or  fluid  situated  between  it  and  the  decidua  vera,  and 
in  this  manner  he  thought  the  foetal  blood  was  oxj^genated  until  the 
fifth  month  of  intra-uterine  life,  when  the  placenta  was  fullj^  formed. 

This  hypothesis,  however,  rests  on  no  accurate  foundation,  for  it  is 
certain  that  the  chorion  villi  do  not  penetrate  the  utricular  glands 
in  the  manner  assumed ;  or,  even  if  they  did,  the  mode  in  which  the 
oxygen  thus  absorbed  by  the  chorion  villi  reaches  the  foetus,  which 
is  separated  from  them  by  the  amnion  and  its  contents,  would  still 
remain  unexplained. 

The  mode  in  which  the  oxygenation  of  the  foetal  blood  is  effected 
before  the  formation  of  the  placenta  remains,  therefore,  as  yet  un- 
known. After  the  development  of  that  organ,  however,  it  is  less 
diflfioult  to  understand,  for  the  foetal  blood  is  everywhere  brought 
into  such  close  contact  with  the  maternal,  in  the  numerous  minute 
ramifications  of  the  umbilical  vessels,  that  the  interchange  of  gases 
can  readily  be  effected.  The  activity  of  respiration  is  doubtless  much 
less  than  in  extra-uterine  life,  for  the  waste  of  tissue  in  the  foetus  is 
necessarily  comparatively  small,  from  the  fact  of  its  being  suspended 
in  a  fluid  medium  of  its  own  temperature,  and  from  the  absence  of 
the  processes  of  digestion  and  of  respiratory  movements.  The  quan- 
tity of  carbonic  acid  formed  would,  therefore,  be  much  less  than  after 
birth,  and  there  would  be  a  correspondingly  small  call  for  oxygena- 
tion of  venous  circulation. 

3.  Circulxtion. — The  functions  of  the  lungs  being  in  abeyance,  it 
is  necessary  that  all  the  foetal  blood  should  be  carried  to  the  placenta 
to  receive  oxygen  and  nutritive  materials.  To  understand  the  mode 
in  which  this  is  effected,  we  must  bear  in  mind  certain  peculiarities 
in  the  circulatory  system  which  disappear  after  birth. 

1.  The  two  sides  of  the  fcetal  heart  are  not  separate,  as  in  the 
adult.  The  right  ventricle  in  the  adult  sends  also  the  venous  blood 
to  the  lungs,  through  the  pulmonary  arteries,  to  be  aerated  by  con- 
tact with  the  atmosphere.  In  the  foetus,  however,  only  sufficient 
blood  is  passed  through  the  pulmonary  arteries  to  insure  their  being 
pervious  and  ready  to  carry  blood  to  the  lungs  immediately  after 
birth. 

9 


122  PREGNANCY. 

An  aperture  of  communication,  the  foramen  ovale^  exists  between 
tlie  two  auricles,  wliicli  is  arranged  so  as  to  permit  the  blood  reach- 
ing the  right  auricle   to  pass  freely   into  the  left,  but   not  vice  versa. 
By  this  means  a  large  portion  of  the  blood  reach- 
FiG.  67.  ing  the  heart  through  the  vena^  cavse.,  instead  of 

passing,  as  in  the  adult,  into  the  right  ventricle, 
is  directed  into  the  left  auricle. 

2.  Even  with  this  arrangement,  however,  a 
larger  portion  of  blood  would  pass  into  the  pul- 
monary arteries  than  is  required  for  transmission 
to  the  lungs,  and  a  further  provision  is  made  to 
prevent  its  going  to  them  by  means  of  a  foetal 
vessel,  the  ductus  arteriosus  (Fig.  67),  which  arises 
Diagram  of  Fcetai  Heart,  from  the  poiut  of  bifurcation  of  the  pulmonary 
(After  Daiton.)  artcrics,  and  opens  into  the   arch  of  the  aorta. 

'^- ■^'^^^^-  Iq  consequence  of  this  arrangement  only  a  very 

2.  Pulmonary  artery.  J-.  p  ,  i       ii         i  i  .il       1  in 

3,3.  Pulmonary brauches.     Small  portiou  oi  the  blood  rcachcs  the  lungs  at  ajl. 
4.  Ductus  arteriosus.  3.    The  foetal   hypogastric   arteries   are    con- 

tinued into  two  large  arterial  trunks,  which  pass- 
ing into  the  cord,  form  the  umhilical  arteries^  and  carry  the  impure 
foetal  blood  into  the  placenta. 

4.  The  purified  blood  is  collected  into  the  single  KmJjilical  vein, 
through  which  it  is  carried  to  the  under  surface  of  the  liver,  from 
which  point  it  is  conducted,  by  means  of  another  special  foetal  vessel 
the  ductus  venosus^  into  the  ascending  vena  cava,  and  the  right  auricle. 

Course  of  the  Foetal  Circulation. — In  order  to  understand  the  course 
of  the  foetal  blood,  it  may  be  most  conveniently  traced  from  the  point 
where  it  reaches  the  under  surface  of  the  liver  through  the  umbilical 
vein.  Part  of  it  is  distributed  to  the  liver  itself,  but  the  greater 
quantity  is  carried  directly  into  the  vena  cava,  through  the  ductus 
venosus.  The  vena  cava  also  receives  the  blood  from  the  foetal  veins 
of  the  lower  extremities,  and  that  portion  of  the  blood  of  the  um 
bilical  vein  which  has  passed  through  the  liver.  This  mixed  blood 
is  carried  up  to  the  right  auricle,  from  which  by  far  the  greater  part 
of  it  is  iiumediately  directed  into  the  left  auricle,  through  the  fora- 
men ovale.  From'  thence  it  passes  into  the  left  ventricle,  which  sends 
the  greater  part  of  it  into  the  head  and  upper  extremities  through 
the  aorta,  a  comparatively  small  quantity  being  transmitted  to  the  ' 
inferior  extremities.  The  blood  which  is  thus  sent  to  the  upper  part 
of  the  body  is  collected  into  the  vena  cava  superior,  by  which  it  is 
thrown  into  the  right  auricle.  Here  the  mass  of  it  is  probably  di- 
rected into  the  right  ventricle,  which  expels  it  into  the  pulmonary 
arteries,  and  from  thence  through  the  ductus  arteriosus  into  the 
descending  aorta.  By  this  arrangement  it  will  be  seen  that  the  de- 
scending aorta  conveys  to  the  loAver  part  of  the  body  the  compara- 
tively impure  blood  which  has  already  circulated  through  the  head, 
neck,  and  upper  extremities.  From'  the  descending  aorta  a  small 
quantity  of  blood  is  conveyed  to  the  lower  extremities,  the  greater 
part  of  "it  being  carried  for  purification  to  the  placenta  through  the 
umbilical  arteries. 


ANATOMY    AND    PHYSIOLOGY    OF    THE    FCETUS. 


123 


Fig.  G8. 


Estahlishment  of  Independent  Circulaiion. — As  soon  as  tlie  child  is 
born  it  generally  cries  loudly,  and  inflates  its  lungs,  and,  in  conse- 
quence, the  pulmonary  arteries  are  dilated,  and  the  greater  portion 
of  the  blood  of  the  right  ventricle  is  at  once  sent  to  the  lungs,  from 
whence,  after  being  arterialized,  it  is  returned  to  the  left  auricle, 
through  the  pulmonary  veins.  The  left  auricle,  therefore,  receives 
more  blood  than  before,  the  right  less,  and  the  placental  circulation 
being  arrested,  no  more  passes  through  the  umbilical  vein.  In  con- 
sequence of  this,  the  pressure  of  the  blood  in  the  two  auricles  is 
equalized,  the  mass  of  the  blood  in  the  right  auricle  no  longer  passes 
into  the  left  (the  valve  of  the  foramen  ovale  being  closed  by  the 
equal  pressure  on  both  sides),  but  dircctlv  into  the  right  ventricle 
and  from  thence  into  the  pulmonary  arteries,  and  the  ductus  arte- 
riosus soon  collapses  and  becomes  impervious.  The  mass  of  blood 
in  the  descending  aorta  no  longer  finds  its  way  into  the  hypogastric 
arteries,  but  passes  into  the  lower  extremities,  and  the  adult  circu- 
lation is  established. 

Changes  after  Birth. — The  changes  which  take  place  in  tempo- 
rary vascular  arrangements  of  the  foetus,  prior  to  their  complete  dis- 
appearance, are  of  some  practical  interest. 
The  ductus  arteriosus,  as  has  been  said, 
collapses,  chiefly  because  the  mass  of  blood 
is  drawn  to  the  lungs,  and  partly,  perhaps, 
by  its  own  inherent  contractility.  Its 
walls  are  found  to  be  thickened,  and  its 
canal  closes,  first  in  the  centre,  and  subse- 
quently at  its  extremities,  its  aortic  end 
remaining  longer  pervious  on  account  of 
the  greatar  pressure  of  blood  from  the  left 
side  of  the  heart  (Fig.  68).  Practical  clos- 
ure occurs  within  a  few  days  after  birth, 
althouo;h  Flourens  states  that  it  is  not 
completely  obliterated  until  eighteen 
months  or  two  years  have  elapsed.^  Ac- 
cording to  Schroeder,  its  walls  unite  with- 
out the  formation  of  any  thrombus.  The 
foramen  ovale  is  soon  closed  by  its  valve, 

which  contracts  adhesion  with  the  edges  of  the  aperture,  so  as  effect- 
ually to  occlude  it.  Sometimes,  however,  a  small  canal  of  commu- 
nication between  the  two  auricles  may  remain  pervious  for  many 
months,  or  even  a  year  and  more,  without,  however,  any  admixture 
of  blood  occurring.  A  permanently  patulous  condition  of  this  aper- 
ture, however,  sometimes  exists,  giving  rise  to  the  disease  known  as 
cyanosis. 

The  umbilical  arteries  and  veins,  and  the  ductus  venosus  soon  also 
become  impermeable,  in  consequence  of  concentric  hypertrophy  of 
their  tissues  and  collapse  of  their  walls.  The  closure  of  the  former 
is  aided  bv  the  formation  of  coagula  in  their  interior.     According  to 


Diagram  of  Heart  of  Infant. 
(After  Dalton.) 

1.  Anrta.  2.  Pulmonary  Artery. 
3,  3.  Pulmonary  branches.  4.  Duc- 
tus r.rterlosus  becoming  obliterated. 


'  Acad,  des  Sciences,  1854. 


124  PREGNANCY. 

Eobin,  a  longer  time  than  is  usually  supposed  elapses  before  they 
become  completely  closed,  the  vein  remaining  pervious  until  the 
twentieth  or  thirtieth  day  after  delivery,  the  arteries  for  a  month  or 
six  weeks.  He  has  also  described^  a  remarkable  contraction  of  the 
umbilical  vessels  within  their  sheaths,  at  the  point  where  they  leave 
the  abdominal  walls,  which  takes  place  within  three  or  four  days 
after  birth,  and  seems  to  prevent  hemorrhage  taking  place  when  the 
cord  is  detached. 

Function  of  the  Liver. — The  liver,  from  it  proportionately  large 
size,  apparently  plays  an  important  part  in  the  foetal  economy.  It 
is  not  until  about  the  fifth  month  of  utero-gestation  that  it  assumes 
its  characteristic  structiire,  and  forms  bile,  previous  to  that  time  its 
texture  being  soft  and  undeveloped.  According  to  Claude  Bernard, 
after  this  period  one  of  its  most  important  offices  is  the  formation  of 
suafar,  which  is  found  in  much  laro'er  amount  in  the  foetus  than  after 
birth.  Sugar  is,  however,  found  in  the  foetal  structures  long  before 
the  development  of  the  liver,  especially  in  the  mucous  and  cutaneous 
tissues,  and  it  seems  probable  that  these,  as  well  as  the  placenta  itself, 
then  fulfil  the  glycogenic  function,  afterwards  chiefly  performed  by 
the  liver.  The  bile  is  secreted  after  the  fifth  month  of  pregnancy, 
and  passes  into  the  intestinal  canal,  and  is  subsequently  collected  in 
the  gall-bladder.  By  some  physiologists  it  has  been  supposed  that 
the  liver,  during  intra-uterine  life,  was  the  chief  seat  of  depuration 
of  the  carbonic  acid  contained  in  the  venous  blood  of  the  foetus.  It 
is,  however,  more  generally  believed  that  this  is  accomplished  solely 
in  the  placenta.  The  bile,  mixed  with  the  mucous  secretion  of  the 
intestinal  tract,  forms  the  meconium  which  is  contained  in  the  intes- 
tmes  of  the  foetus,  and  which  collects  in  them  during  the  whole  period 
of  intra-uterine  life.  It  is  a  thick,  tenacious,  greenish  substance, 
"vvhich  is  voided  soon  after  birth  in  considerable  quantity. 

The  Urine. — Urine  is  certainly  formed  during  intra-uterine  life, 
as  is  proved  by  the  fact  familiar  to  all  accoucheurs,  that  the  bladder 
is  constantly  emptied  instantly  after  birth.  It  has  generally  been 
supposed  that  the  foetus  voided  its  urine  into  the  cavity  of  the  am- 
nion, and  the  existence  of  traces  of  urea  in  the  liquor  amnii,  as  well 
as  some  cases  of  imperforate  urethra,  in  which  the  bladder  was  found 
to  be  enormously  distended,  and  some  congenital  hydronephrosis 
associated  with  impervious  ureters,  have  been  supposed  to  corrobo- 
rate this  assumption.  The  question  has  been  very  fully  studied  by 
Joulin,  who  has  collected  together  a  large  number  of  instances  in 
which  there  was  imperforate  urethra  without  any  undue  distension 
of  the  bladder.  He  holds  also  that  the  amount  of  urea  found  in  the 
liquor  amnii  is  far  too  minute  to  justify  the  conclusion  that  the  urine 
of  the  foetus  was  habitually  poured  into  it,  although  a  small  quantity 
may,  he  thinks,  escape  into  it  from  time  to  time ;  and  he,  therefore, 
believes  that  the  urine  of  the  foetus  is  only  secreted  regularly  and 
abundantly  after  birth,  and  that  during  intra-uterine  life  its  retention 
is  not  likely  to  give  rise  to  any  functional  disturbance.^ 

'  Acad,  des  Sciences,  1860.  2  Acad,  des  Sciences,  p.  301. 


PREGNANCY.  125 

Function  of  the  Nervous  System. — There  is  no  doubt  that  the 
nervous  sj'stera  acts  to  a  considerable  extent  during  intra-uterine 
life,  and  some  authors  have  even  supposed  that  the  foetus  was  en- 
dowed with  the  power  of  making  instinctive  or  voluntary  movements 
for  the  purpose  of  adapting  itself  to  the  form  of  the  uterine  cavity. 
There  can  be  no  question,  however,  that  the  movements  the  foetus 
performs  are  purely  reflex  and  automatic.  That  it  responds  to  a 
stimulus  applied  to  the  cutaneous  nerves  is  proved  by  the  experi- 
ments of  Tyler  Smith,  who  laid  bare  the  amnion  in  pregnant  rabbits, 
and  found  that  the  foetus  moved  its  limbs  when  these  were  irritated 
through  it.  Pressure  on  the  mother's  abdomen,  cold  applicatiofis, 
and  similar  stimuli,  will  also  produce  energetic  foetal  movements. 
The  gray  matter  of  the  brain  in  the  new-born  child  is,  however,  quite 
rudimentary  in  its  structure,  and  there  is  no  evidence  of  intelligent 
action  of  the  nervous  system  until  some  time  after  birth,  and  a  fortiori 
during  pregnancy. 


CHAPTEE    III. 

PREGNANCY. 

As  soon  as  conception  has  taken  place  a  series  of  remarkable 
changes  commence  in  the  uterus,  which  progress  until  the  termina- 
tion of  pregnancy,  and  are  well  worthy  of  careful  study.  They  pro- 
duce those  marvellous  modifications  which  effect  the  transformation 
of  the  small  undeveloped  uterus  of  the  non-pregnant  state  into  the 
large  and  fully-developed  uterus  of  pregnane}',  and  have  no  parallel 
in  the  whole  animal  economy. 

A  knowledge  of  them  is  essential  for  the  proper  comprehension 
of  the  phenomena  of  labor,  and  for  the  diagnosis  of  pregnancy  which 
the  practitioner  is  so  frequently  called  upon  to  make.  Excluding 
the  varieties  of  abnormal  pregnancy,  which  will  be  noticed  in  an- 
other place,  we  shall  here  limit  ourselves  to  a  consideration  of  the 
modifications  of  the  maternal  organism  which  result  from  simple 
and  natural  gestation. 

Changes  in  the  Uterus. — The  unimpregnated  uterus  measures  2| 
inches  in  length,  and  weighs  about  1  oz.,  while  at  the  full  term  of 
pregnancy  it  has  so  immensely  grown  as  to  weigh  24  oz.,  and  meas- 
ure 12  inches.  This  growth  commences  as  soon  as  the  ovum  reaches 
the  uterus,  and  continues  uninterruptedly  until  delivery.  In  the 
early  months  the  uterus  is  contained  entirely  in  the  cavity  of  the 
pelvis,  and  the  increase  of  size  is  only  apparent  on  vaginal  examina- 
tion, and  that  with  diiftculty.  After  the  third  month  the  enlarge- 
ment is  chiefly  in  the  lateral  direction,  so  that  the  whole  body  of  the 


126 


PREGNANCY. 


Fig.  69. 


uterus  assumes  more  of  a  spherical  shape  than  in  the  non-pregnant 
state.  If  an  opportunity  of  examining  the  gravid  uterus  post  mor- 
tem should  occur  at  this  time,  it  will  be  found  to  have  the  form  of  a 
sphere  flattened  somewhat  posteriorly,  and  bulging  anteriorly. 

After  the  ascent  of  the  organ  into  the  abdomen,  it  develops  more 
in  the  vertical  direction,  so  tiiat  at  term  it  has  the  form  of  an  ovoid, 
with  its  large  extremity  above  and  its  narrow  end  at  the  cervix  uteri, 
and  its  longitudinal  axis  corresponds  to  the  long  diameter  of  the 
mother's  abdomen,  provided  the  presentation  be  either  of  the  head 
or  breech.  The  anterior  surface  is  now  even  more  distinctly  pro- 
jecting  than  before — a  fact  which  is  explained  by  the  proximity  of 
the  posterior  surface  to  the  rigid  spinal  column  behind,  while  the 
anterior  is  in  relation  with  the  lax  abdominal  parietes,  which  yield 
readily  to  ]3ressurc,  and  so  allow  of  the  more  marked  prominence  of 
the  anterior  uterine  wall. 

Change  in  Situation. — Before  the  gravid  uterus  has  risen  out  of  the 
pelvis  no  appreciable  increase  in  the  size  of  the  abdomen  is  percep- 
tible. On  the  contrary,  it  is  an  old  observation  that  at  this  early 
stage  of  pregnancy  the  abdomen  is  flatter  than  usual,  on  account  of 
the  partial  descent  of  the  uterus  in  the  pelvic  cavity  as  a  result  of  its 
increased  weight.  As  the  growth  of  the  organ  advances  it  soon  be- 
comes too  large  to  be  contained  any  longer  within  the  pelvis,  and 

about  the  middle  of  the  third  or  the 
beginning  of  the  fourth  month  the 
fundus  rises  above  the  pelvic  brim 
• — not  suddenly,  as  is  often  errone- 
ously thought,  but  slowly  and  gradu- 
ally— when  it  may  be  felt  as  a  smooth 
rounded  swelling. 

Size  at  various  Periods  of  Prey- 
nancy.' — It  is  about  this  time  that 
the  movements  of  the  foetus  first 
become  appreciable  to  the  mother, 
when  "  quichenincf  is  said  to  have 
taken  place.  Towards  the  end  of 
the  fourth  month  the  uterus  reaches 
to  about  three  fingers'  breadth  above 
the  symphysis  pubis.  About  the 
fifth  month  it  occupies  the  hypo- 
gastric region,  to  which  it  imparts 
a  marked  projection,  and  the  altera- 
tion in  the  figure  is  now  distinctly 
perceptible  to  visual  examination. 
About  the  sixth  month  it  is  on  a 
level  with,  or  a  little  above,  the  um- 
bilicus. About  the  seventh  month  it  is  about  two  inches  above  the 
umbilicus,  which  is  now  projecting  and  prominent,  instead  of  de- 
pressed, as  in  the  non-pregnant  state.  During  the  eighth  and  ninth 
months  it  continues  to  increase  until  the  summit  of  the  fundus  is 
immediately  below  the  ensiform  cartilage  (Fig.  69).     A  knowledge 


Size  of  Uterus  at  various  Periods  of 
Prcgnaucy. 


PREaNANCY.  127 

of  the  size  of  tlie  uterine  tumor  at  various  periods  of  pregnancy,  as 
thus  indicated,  is  of  considerable  practical  importance,  as  forming 
the  only  guide  by  which  we  can  estimate  the  probable  period  of 
delivery  in  certain  cases  in  which  the  usual  data  for  calculation  are 
absent,  as,  for  example,  when  the  patient  has  conceived  during  lacta- 
tion. 

The  Uterus  Sinks  hefore  Delivery. — For  about  a  week  or  more 
before  labor  the  uterus  generally  sinks  somewhat  into  the  pelvic 
cavity,  in  consequence  of  the  relaxation  of  the  soft  parts  -which  pre- 
cedes delivery,  and  the  patient  now  feels  herself  smaller  and  lighter 
than  before.  This  change  is  familiar  to  all  child-bearing  women, 
to  whom  it  is  known  as  "  the  lightening  before  labor." 

The  Direction  of  the  Uterus. — While  the  uterus  remains  in  the 
pelvis  its  longitudinal  axis  varies  in  direction,  much  in  the  same  way 
as  that  of  the  non-pregnant  uterus,  sometimes  being  more  or  less 
vertical,  at  others  in  a  state  of  anteversion  or  partial  retroversion. 
These  variations  are  probably  dependent  on  the  distension  or  empti- 
ness of  the  bladder,  as  its  state  must  necessarily  affect  the  position 
of  the  movable  organ  poised  behind  it.  After  the  uterus  has  risen 
into  the  abdomen  its  tendency  is  to  project  forwards  against  the  ab- 
dotninal  wall,  which  forms  its  chief  support  in  front.  In  the  erect 
position  the  long  axis  of  the  uterine  tumor  corresponds  with  the  axis 
of  the  pelvic  brim,  forming  an  angle  of  about  30"^  with  the  horizon. 
In  the  semi-recumbent  position,  on  the  other  hand,  as  Duncan^  has 
pointed  out,  its  direction  becomes  much  more  nearly  vertical.  In 
women  who  have  borne  many  children,  the  abdominal  parietes  no 
longer  afford  an  efficient  support,  and  the  uterus  is  displaced  ante- 
riorly, the  fundus  in  extreme  cases  even  hanging  downwards. 

Lateral  Obliquity  of  the  Uterus. — In  addition  to  this  anterior  ob- 
liquity, on  account  of  the  projection  of  the  spinal  column,  the  uterus 
is  very  generally  also  displaced  laterally,  and  sometimes  to  a  very 
marked  degree,  so  that  it  may  be  felt  entirely  in  one  flank,  instead 
of  in  the  centre  of  the  abdomen.  In  a  large  proportion  of  cases  this 
lateral  deviation  is  to  the  right  side,  and  many  hypotheses  have 
been  brought  forward  to  explain  this  fact,  none  of  them  being  satis- 
factory. Thus,  it  has  been  supposed  to  depend  on  the  greater  fre- 
quency with  which  women  lie  on  their  right  side  during  sleep,  nn  the 
greater  use  of  the  right  leg  during  walking,  on  the  supposed  com- 
parative shortness  of  the  right  round  ligament,  which  drags  the 
tumor  to  that  side,  or  on  the  frequ.ent  distension  of  the  rectum  on  the 
left  side,  which  prevents  the  uterus  being  displaced  in  that  direction. 
Of  these  the  last  is  the  cause  which  seems  most  constantly  in  opera- 
tion, and  most  likely  to  produce  the  effect. 

Changes  in  the  Direction  of  the  Cervix.— li^\\Q  cervix  must  obviously 
adapt  itself  to  the  situation  of  the  body  of  the  uterus.  We  find, 
therefore,  that  in  the  early  months,  when  the  uterus  lies  low  in  the 
pelvis,  it  is  more  readily  within  reach.  After  the  ascent  of  the 
uterus,  it  is  drawn  up,  and  frequently  so  much  so  as  to  be  reached 

■   Researches  in  Obstetrics,  p.  10. 


128  PREGNANCY. 

with  difficulty.  When  the  uterus  is  much  ante  verted,  as  is  so  often 
the  case,  the  os  is  displaced  backwards,  so  that  it  cannot  be  felt  at 
all  by  the  examining  finger. 

Relation  of  the  Uterus  to  the  Surroundimj  Parts. — Towards  the  end 
of  pregnancy  the  greater  part  of  the  anterior  surface  of  the  uterus  is 
in  contact  with  the  abdominal  wall,  its  lower  portion  resting  on  the 
posterior  surface  of  the  symphysis  pubis.  The  posterior  surface  rests 
on  the  spinal  column,  while  the  small  intestines  are  pushed  to  either 
side,  the  large  intestines  surrounding  the  uterus  like  an  arch. 

Changes  in  the  Uterine  Parietes.- — -The  great  distension  of  the  uterus 
during  pregnancy  was  formerly  supposed  to  be  mainly  due  to  the 
mechanical  pressure  of  the  enlarging  ovum  within  it.  If  this  were 
so,  then  the  uterine  walls  would  be  necessarily  much  thinner  than  in 
the  non-pregnant  state.  This  is  well  known  not  to  be  the  case,  and 
the  immense  increase  in  the  size  of  the  uterine  cavity  is  to  be  ex- 
plained by  the  hypertrophy  of  its  walls.  At  the  full  period  of  preg- 
nancy the  thickness  of  the  uterine  parietes  is  generally  about  the 
same  as  that  of  the  non-pregnant  uterus,  rather  more  at  the  placental 
site,  and  less  in  the  neighborhood  of  the  cervix.  Their  thickness, 
however,  varies  in  different  cases,  and  in  some  women  they  are  so 
thin  as  to  admit  of  the  foetal  limbs  being  very  readily  made  out  by 
palpation.  Their  density  is,  however,  always  much  diminished,  and, 
instead  of  being  hard  and  inelastic,  they  become  soft  and  yielding  to 
pressure.  This  change  coincides  with  the  commencement  of  preg- 
nancy, of  which  it  forms,  as  recognizable  in  the  cervix,  one  of  the 
earliest  diagnostic  marks.  At  a  more  advanced  period  it  is  of  value 
as  admitting  a  certain  amount  of  yielding  of  the  uterine  walls  to 
movements  of  the  foetus,  thus  lessening  the  chance  of  their  being 
injured. 

Chanfjes  in  the  Cervix  during  Pregnancy. — Yery  erroneous  views 
have  long  been  taught,  in  most  of  our  standard  works  on  midwifery, 
as  to  the  changes  which  occur  in  the  cervix  uteri  during  pregnancy. 
It  is  generally  stated  that,  as  pregnancy  advances,  the  cervical  cavity 
is  greatly  diminished  in  length,  in  consequence  of  its  being  gradually 
drawn  up  so  as  to  form  part  of  the  general  cavity  of  the  uterus,  so 
that  in  the  latter  months  it  no  longer  exists.  In  almost  all  midwifery 
works  accurate  diagrams  are  given  of  this  progressive  shortening  of 
the  cervix  (Figs.  70  to  73).  The  cervix  is  generally  described  as 
having  lost  one-half  of  its  length  at  the  sixth  month,  two-thirds  at 
the  seventh,  and  to  be  entirely  obliterated  in  the  eighth  and  ninth. 
The  correctness  of  these  views  was  first  called  in  question  in  recent 
times  by  Stoltz,  in  1826,  but  Dr.  Duncan,^  in  an  elaborate  historical 
paper  on  the  subject,  has  shown  that  Stoltz  was  anticipated  by  Weit- 
brech  in  1750,  and,  to  a  less  degree,  by  Eoederer  and  other  writers. 
This  opinion  is  now  pretty  generally  admitted  to  be  correct,  and  is 
upheld  by  Cazeaux,  Arthur  Farre,  Duncan,  and  most  modern  obstet- 
ricians. Indeed,  various  post  mortem  examinations  in  advanced 
pregnancy  have  shown  that  the  cavity  of  the  cervix   remains   in 

'  Researches  in  Obstetrics. 


PREGNANCY, 


129 


reality  of  its  normal  length  of  one  inch,  and  it  can  often  be  measured 
during  life  by  the  examining  finger,  on  account  of  its  patulous  state 

Figs.  70,  71,  72,  73. 


Supposed  Shortening'  of  the  Cervix  at  the  Third,  Sixth,  Eighth,  and  Mnth  Months  of  Pregnancy,  as 

figured  iu  Obstetric  Works. 

(Fig.   74).      During  the   fortnight  immediately  preceding  deliver}^, 
however,  a  real  shortening  or  obliteration  of  the  cervical  cavity  takes 

Fig.  74. 


Cervix  from  a  Woman  Dying  in  the  Eighth  Month  of  Pregnancy.     (After  Duncan.) 

place ;  but  this,  as  Duncan  has  pointed  out,  seems  to  be  due  to  the 
incipient  uterine  contractions,  which  prepare  the  cervix  for  labor. 


130  PREGNANCY. 

Apparent  Shortening. — There  is,  no  doubt,  an  apparent  shortening 
of  the  cervix  always  to  be  detected  during  pregnancy,  but  this  is  a 
fallacious  and  deceptive  feeling,  due  to  the  softness  of  the  tissue  of 
the  cervix,  which  is  exceedingly  characteristic  of  pregnancy,  and 
which  to  an  experienced  linger  affords  one  of  its  best  diagnostic 
marks. 

Shortening  of  the  Cervix. — In  the  non-pregnant  state  the  tissue  of 
the  cervix  is  hard,  firm,  and  inelastic.  When  conception  occurs, 
softening  begins  at  the  external  os,  and  proceeds  gradually  and  slowly 
iTpwards  until  it  involves  the  whole  of  the  cervix.  By  the  end  of 
the  fourth  month  both  lips  of  the  os  are  thick,  softened,  and  velvety 
to  the  touch,  giving  a  sensation,  likened  by  Cazeaux  to  that  produced 
by  pressing  on  a  table  through  a  thick,  soft  cover.  By  the  sixth 
month  at  least  one-half  of  the  cervix  is  thus  altered,  and  by  the 
eighth  the  whole  of  it,  and  so  much  so  that  at  this  time  those  unac- 
customed to  vaginal  examination  experience  some  difficulty  in  dis- 
tinguishing it  from  the  vaginal  walls.  It  is  this  softening,  then, 
which  gives  rise  to  the  apparent  shortening  of  the  cervix  so  gene- 
rally described,  and  it  is  an  invariable  concomitant  of  pregnancy 
except  in  some  rare  cases  in  which  there  has  been  antecedent  morbid 
induration  and  hypertrophic  elongation  of  the  cervix.  If,  therefore, 
on  examining  a  woman  supposed  to  be  advanced  in  pregnancy,  we 
find  the  cervix  to  be  hard  and  projecting  into  the  vaginal  canal,  we 
may  safely  conclude  that  pregnancy  does  not  exist.  The  existence 
of  softening,  however,  it  must  be  remembered,  will  not  of  itself 
justify  an  opposite  conclusion,  as  it  may  be  produced,  to  a  very  con- 
siderable extent,  by  various  pathological  conditions  of  the  uterus. 

Tlie  Os  Uteri  is  generally  Patulous. — At  the  same  time  that  the 
tissue  of  the  cervix  is  softened,  its  cavity  is  widened,  and  the  external 
OS  becomes  patulous.  This  change  varies  considerably  in  primiparae 
and  multiparse.  In  the  former  the  external  os  often  remains  closed 
until  the  end  of  pregnancy ;  but  even  in  them  it  generally  becomes 
more  or  less  patulous  after  the  seventh  month,  and  admits  the  tip  of 
the  examining  finger.  In  women  who  have  borne  children  this 
change  is  much  more  marked.  The  lips  of  the  external  os  are  in 
them  generally  fissured  and  irregular,  from  slight  lacerations  of  its 
tissue  in  former  labors.  It  is  also  sufficiently  open  to  admit  the  tip 
of  the  finger,  so  that  in  the  latter  months  of  pregnancy  it  is  often 
quite  possible  to  touch  the  membranes,  and  through  them  to  feel  the 
presenting  part  of  the  child. 

Changes  in  the  Texture  of  the  Uterine  Tissues. — The  remarkable 
increase  in  size  of  the  uterus  during  pregnancy  is,  as  we  have  seen, 
chiefly  to  be  explained  by  the  growth  of  its  structures,  all  of  which 
are  modified  during  gestation.  The  peritoneal  covering  is  consider- 
ably increased,  so  as  still  to  form  a  complete  covering  to  the  uterus 
when  at  its  largest  size.  William  Hunter  supposed  that  its  extension 
was  affected  rather  by  the  unfolding  of  the  layers  of  the  broad  liga- 
ment, than  by  growth.  That  the  layers  of  the  broad  ligament  do 
unfold  during  gestation,  especially  in  the  early  months,  is  probable ; 
but  this  is  not  sufficient  to  account  for  the  complete  investment  of 


PREGNANCY.  131 

the  uterus,  and  it  is  certain  that  the  peritoneum  grows  pari  jjassu 
with  the  enlargement  of  the  uterus.  In  addition  there  is  a  new  for- 
mation of  fibrous  tissue  between  the  peritoneal  and  the  muscular 
coats,  which  aftbrds  strength,  and  diminishes  the  risk  of  laceration 
during  labor. 

Miiscular  Coat. — The  hypertrophy  of  the  muscular  tissue  of  the 
uterus  is,  however,  the  most  remarl^able  of  the  changes  produced  by 
pregnancy.  Not  only  do  the  previously-existing  rudimentary  fibre- 
cells  become  enormously  increased  in  size — so  as  to  measure,  accord- 
ing to  Kblliker,  from  seven  to  eleven  times  their  former  length,  and 
from  two  to  five  times  their  former  breadth — but  new  unstriped 
fibres  are  largely  developed,  especially  in  the  inner  layers.  These 
new  cells  are  chiefly  found  in  the  first  months  of  pregnancy,  and 
their  growth  seems  to  be  completed  by  the  sixth  month.  The  con- 
nective tissue  between  the  muscular  layers  is  also  largely  increased 
in  amount.  The  weight  of  the  muscular  tissue  of  the  gravid  uterus 
is,  therefore,  much  increased,  and  ft  has  been  estimated  by  Heschl 
that  it  weighs  at  term  from  1  to  1.5  lbs.,  that  is,  about  sixteen  times 
more  than  in  the  unimpregnated  state.  This  great  development  of 
the  muscular  tissue  admits  of  its  dissection  in  a  way  which  is  quite 
impossible  in  the  unimpregnated  state,  and  the  recent  researches  of 
Helie  (p.  53)  enable  us  to  understand  much  better  than  before  how 
the  muscles  forming  the  walls  of  the  gravid  uterus  act  during  the 
expulsion  of  the  child. 

The  changes  in  the  mucous  coat  of  the  uterus,  Avhich  result  in  the 
formation  of  the  decidua,  have  already  been  discussed  at  length  else- 
where (p.  91). 

Circulatory  Apparatus. — The  circulatory  apparatus  of  the  uterus 
during  pregnancy  has  been  described  when  the  anatomy  of  the  pla- 
centa was  under  consideration  (p.  105). 

Lympjhatics. — The  lymphatics  are  much  increased  in  size ;  and  re- 
cent theories  on  the  production  of  certain  puerperal  diseases  attribute 
to  them  a  more  important  action  than  has  been  commonly  assigned 
to  them. 

Nerves. — -The  question  of  the  growth  of  the  nerves  has  been  hotly 
discussed.  Eobert  Lee  took  the  foremost  place  among  those  who 
maintain  that  the  nerves  of  the  uterus  share  the  general  growth  of 
its  other  constituent  parts.  Dr.  Snow  Beck,  however,  believed  that 
they  remain  of  the  same  size  as  in  the  unimpregnated  state,  and  this 
view  is  supported  by  Hirchfeld,  Eobin,  and  other  recent  writers. 
Robin  thought  that  there  was  an  apparent  increase  in  the  size  of  the 
nerve-tubes,  which,  however,  is  really  due  to  increase  in  the  neuri- 
lemma. Kilian  describes  the  nerves  as  increasing  in  length  but  not 
in  thickness  ;  while  Schroeder  states  that  they  participate  equally 
with  the  lymphatics  in  the  enlargement  the  latter  undergo.  Which- 
ever of  these  views  may  ultimately  be  found  to  be  correct,  it  is  cer- 
tain that  analogy  would  lead  us  to  expect  an  increase  of  nervous,  as 
well  as  of  vascular  supply. 

General  Modifi.ccdion  in  tlie  Body  produced  hy  Pre< jnancy . — It  is  not 
in  the  iiterus  alone  that  pregnancy  is  found  to  produce  modifications 


132  PREGNANCY. 

of  importance.  There  are  few  of  the  more  important  functions  of 
the  body  which  are  not,  to  a  greater  or  less  extent,  affected  ;  to  some 
of  these  it  is  necessary  briefly  to  direct  attention,  inasmuch  as,  when 
carried  to  excess,  they  produce  tliose  disorders  which  often  compli- 
cate gestation,  and  which  prove  so  distressing  and  even  dangerous 
to  the  patients.  Such  of  them  as  are  apparent  and  may  aid  us  in 
diagnosis  are  discussed  in  the  chapter  which  treats  of  the  signs  and 
symptoms  of  pregnancy  ;  in  this  place  it  is  only  necessary  to  refer  to 
those  which  do  not  properly  fall  into  that  category. 

Changes  in  the  Blood.- — -Amongst  those  which  are  most  constant 
and  important  are  the  alterations  in  the  composition  of  the  blood. 
The  opinion  of  the  profession  on  this  subject  has,  of  late  years,  under- 
gone a  remarkable  change.  Formerly  in  was  universally  believed 
that  pregnancy  was,  as  the  rule,  associated  with  a  condition  analogous 
to  plethora,  and  that  this  explained  many  characteristic  phenomena 
of  common  occurrence,  such  as  headache,  palpitation,  singing  in  the 
ears,  shortness  of  breath,  and  the  like.  As  a  consequence  it  was 
the  habitual  custom,  not  yet  by  any  means  entirely  abandoned,  to 
treat  pregnant  women  on  an  antiphlogistic  system  ;  to  place  them  on 
low  diet,  to  administer  lowering  remedies,  and  very  often  to  practise 
venesection,  sometimes  to  a  surprising  extent.  Thus  it  was  by  no 
means  rare  for  women  to  be  bled  six  or  eight  times  during  the  latter 
months,  even  when  no  definite  symptoms  of  disease  existed ;  and 
many  of  the  older  authors  record  cases  where  depletion  was  practised 
every  fortnight,  as  a  matter  of  routine,  and,  when  the  symptoms 
were  well  marked,  even  from  fifty  to  ninety  times  in  the  course  of  a 
single  pregnancy. 

Composition  of  the  Blood  in  Pregnancy. — Numerous  careful  analyses 
have  conclusively  proved  that  the  composition  of  the  blood  during 
pregnancy  is  very  generally ^ — -perhaps  it  would  not  be  too  much  to 
say  always — profoundly  altered.  Thus  it  is  found  to  be  more  watery, 
its  serum  is  deficient  in  albumen,  and  the  amount  of  colored  globules 
is  materially  diminished,  averaging,  according  to-  the  analyses  of 
Becquerel  and  Eodier,  111.8  against  127.2  in  the  non-gravid  state. 
At  the  same  time  the  amount  of  fibrine  and  of  extractive  matter  is 
considerably  increased.  The  latter  observation  is  of  peculiar  im- 
portance as  it  goes  far  to  explain  the  frequency  of  certain  thrombotic 
affections,  observed  in  connection  with  pregnancy  a^nd  delivery ;  this 
byperinosis  of  the  blood  is  also  considerably  increased  after  labor  by 
the  quantity  of  effete  material  thrown  into  the  mother's  system  at 
that  time,  to  be  got  rid  of  by  her  emunctories.  The  truth  is,  that 
the  blood  of  the  pregnant  woman  is  generally  in  a  state  much  more 
nearly  approaching  the  condition  of  anasmia  than  of  plethora,  and  it 
is  certain  that  most  of  the  phenomena  attributed  to  plethora  may  be 
explained  equally  well  and  better  on  this  view.  These  changes  are 
much  more  strongly  marked  at  the  latter  end  of  pregnancy  than  at 
its  commencement,  and  it  is  interesting  to  observe  that  it  is  then  that 
the  concomitant  phenomena  alluded  to  are  most  frequently  met  with, 
Cazeaux,  to  whom  we  are  chiefly  indebted  for  insisting  on  the 
practical  bearing  of  these  views,  contends  that  the  pregnant  state  is 


PREGNANCY.  138 

essentiallv  analogous  to  chlorosis,  and  that  it  should  be  so  treated. 
Objection  has  not  unnaturally  been  taken  to  this  theory,  as  implying 
that  a  healthy  and  normal  function  is  associated  with  a  morbid  slate, 
and  it  has  been  suggested  that  this  deteriorated  state  of  the  blood 
may  be  a  wise  provision  of  nature  instituted  for  a  purpose  we  are  not 
as  yet  able  to  understand.  It  may  certainly  be  admitted  that  preg- 
nancy, in  a  perfectly  healthy  state  of  the  system,  should  not  be 
associated  with  phenomena  in  themselves  in  any  degree  morbid.  It 
must  not  be  forgotten,  however,  that  our  patients  are  seldom,  we 
might  safely  say  never,  in  a  state  that  is  physiologically  healthy. 
The  influence  of  civilization,  climate,  occupation,  diet,  and  a  thousand 
other  disturbing  causes  that,  to  a  greater  or  less  degree,  are  always 
to  be  met  with,  must  not  be  left  out  of  consideration.  Making  every 
allowance,  therefore,  for  the  undoubted  fact  that  pregnancy  ouylit  to 
be  a  perfectly  healthy  condition,  it  must  be  conceded,  I  think,  that 
in  the  vast  majority  of  cases  coming  under  our  notice  it  is  not  entirely 
so;  and  the  deductions  drawn  by  Cazeaux,  from  the  numerous 
analyses  of  the  blood  of  pregnant  women,  seem  to  point  strongly  to 
the  conclusion  that  the  general  blood-state  is  one  of  poverty  and 
anemia,  and  that  a  depressing  and  antiphlogistic  treatment  is  dis- 
tinctly contra-indicated. 

Modification  in  certain  Viswra. — Closely  connected  with  the  al- 
tered condition  of  the  blood  is  the  physiological  hypertrophy  of  the 
heart,  which  is  now  well  known  to  occur  during  pregnancy.  This 
was  first  pointed  out  by  Larcher  in  1828,  and  it  has  been  since  veri- 
fied by  numerous  observers.  It  seems  to  be  constant  and  considera- 
ble, and  to  be  a  purely  physiological  alteration  intended  to  meet  the 
increased  exigencies  of  the  circulation,  w^hich  the  complex  vascular 
arrangements  of  the  gravid  uterus  produce.  The  hypertrophy  is 
limited  to  the  left  ventricle :  the  right  ventricle,  as  Avell  as  both  au- 
ricles, being  unaffected.  Blot  estimates  that  the  whole  weight  of  the 
heart  increases  one-fifth  during  gestation.  The  more  recent  re- 
searches of  Ltihlein^  render  it  probable  that  the  hypertrophy  is  less 
than  those  authors  have  supposed.  According  to  Daroziez^  the  heart 
remains  enlarged  during  lactation,  but  diminishes  in  size  immediately 
after  delivery  in  women  who  do  not  suckle,  Avhile  in  women  w^ho 
have  borne  many  children  it  remains  permanently  somewhat  larger 
than  in  nullipara.  Similar  increase  in  the  size  of  other  organs  has 
been  pointed  out  by  various  Avriters,  as,  for  example,  in  the  lym- 
phatics, the  spleen,  and  the  liver.  Tarnier  states  that  in  women  who 
have  died  after  delivery,  the  organs  always  show  signs  of  fatty  de- 
generation. According  to  Gassner  the  whole  body  increases  in  weight 
during  the  latter  months  of  pregnancy,  and  this  increase  is  somewhat 
beyond  that  which  can  be  explained  by  the  size  of  the  womb  and  its 
contents. 

Formation  of  Osteophytes. — Irregular  bony  deposits  between  the 
skull  and  the  dura  mater,  in  some  cases  so  largely  developed  as  to 
line  the  whole  cranium,  have  been  so  frequently  detected  in  women 

'  Zeitschrift  fur  Geburtshiilfc,  etc.,  1876.  «  Gaz.  des  Hopit.  1868. 


134  PREGNANCY. 

who  have  died  during  parturition,  that  thej  are  believed  by  some  to 
be  a  normal  production  connected  with  pregnancy.  Ducrest  found 
these  osteophytes  in  more  than  one-third  of  the  cases  in  which  he 
performed  post-mortem  examinations  during  the  puerperal  period. 
Rokitansky,  who  corroborated  the  observation,  believed  this  peculiar 
deposit  of  bony  matter  to  be  a  physiological,  and  not  a  pathological 
condition  connected  with  pregnancy  ;  but  whether  it  be  so,  or  how 
it  is  produced,  has  not  yet  been  satisfactorily  determined. 

Changes  in  the  Nervous  System. — More  or  less  marked  changes  con- 
nected with  the  nervous  system  are  generally  observed  in  pregnancy, 
and  sometimes  to  a  very  great  extent.  AVhen  carried  to  excess  they 
produce  some  of  the  most  troublesome  disorders  which  complicate 
gestation,  such  as  alterations  in  the  intellectual  functions,  changes  in 
the  disposition  and  character,  morbid  cravings,  dizziness,  neuralgia, 
syncope,  and  many  others.  They  are  purely  functional  in  their  char- 
acter, and  disappear  rapidly  after  delivery,  and  may  be  best  de- 
scribed in  connection  with  the  disorders  of  pregnancy. 

Changes  in  the  Respiratory  Orgaiis. — Respiration  is  often  inter- 
fered with,  from  the  mechanical  results  of  the  pressure  of  the  en- 
larged uterus.  The  longitudinal  dimensions  of  the  thorax  are 
lessened  by  the  upward  displacement  of  the  diaphragm,  and  this 
necessarily  leads  to  some  embarrassment  of  the  respiration,  which 
is,  however,  compensated,  to  a  great  extent,  by  an  increase  in  breadth 
of  the  base  of  the  thoracic  cavity. 

Changes  in  the  Urine. — Certain  changes,  which  are  of  very  con- 
stant occurrence,  in  the  urine  of  pregnant  wonien  have  attracted 
much  attention,  and  have  been  considered  by  many  writers  to  be 
pathognomonic.  They  consist  in  the  presence  of  a  peculiar  deposit, 
formed  when  the  urine  has  been  allowed  to  stand  for  some  time, 
which  has  received  the  name  of  kiestein.  Its  presence  was  known 
to  the  ancients,  and  it  was  particularly  mentioned  by  Savonarola  in 
the  fifteenth  centurj^,  but  it  has  more  especially  been  studied  within 
the  last  thirty  years  by  Eguisier,  Golding  Bird,  and  others.  If  the 
urine  of  a  pregnant  woman  be  allowed  to  stand  in  a  cylindrical  ves- 
sel, exposed  to  light  and  air,  but  protected  from  dust,  in  a  period, 
varying  from  two  to  seven  days,  a  peculiar  flocculent  sediment,  like 
fine  cotton-wool,  makes  its  appearance  in  the  centre  of  the  fluid,  and 
soon  afterwards  rises  to  the  surface  and  forms  a  pellicle,  which  has 
been  compared  to  the  fat  on  cold  mutton-broth.  In  the  course  of  a 
few  days  the  scum  breaks  up  and  falls  to  the  bottom  of  the  vessels. 
On  microscopic  examination  it  is  found  to  be  composed  of  fat  parti- 
cles, with  crystals  of  ammoniaco-magnesium  phosphatesand  phosphate 
of  lime,  and  a  large  quantity  of  vibriones.  These  appearances  are 
generally  to  be  detected  after  the  second  month  of  pregnancy,  and 
up  to  the  seventh  or  eighth  month,  after  which  they  are  rarely  pro- 
duced. Regnauld  explains  their  absence  during  the  latter  months 
of  gestation  by  the  presence  in  the  urine,  at  that  time,  of  free  lactic 
acid,  which  increases  its  acidity,  and  prevents  the  decomposition  of 
the  urea  into  carbonate  of  ammonia.  He  believes  that  kiestein  is 
produced  by  the  action  of  free  carbonate  of  ammonia  on  the  phos- 


SIGNS    AND    SYMPTOMS    OF    PREGNANCY.  135 

phate  of  lime  contained  in  the  urine,  and  that  this  reaction  is  pre- 
vented by  the  excess  of  acid. 

Golding  Bird  believed  kiestein  to  be  analogous  to  casein,  to  the 
presence  of  which  he  referred  it,  and  he  states  that  he  has  found  it 
in  twenty-seven  out  of  thirty  cases,  Braxton  Ilicks  so  far  corrobo- 
rates his  view,  and  states  that  the  deposit  of  kiestein  can  be  much 
more  abundantly  produced  if  one  or  two  teaspoonfuls  of  rennet  be 
added  to  the  urine,  since  that  substance  has  the  property  of  coagu- 
lating casein.  Much  less  importance,  however,  is  now  attached  to 
the  presence  of  kiestein  than  formerly,  since  a  precisely  similar  sub- 
stance is  sometimes  found  in  the  urine  of  the  non-pregnant,  especially 
in  anaemic  women,  and  even  in  the  urine  of  men.  Parkes  states  that 
it  is  not  of  uniform  composition,  that  it  is  produced  by  the  decompo- 
sition of  urea,  and  consists  of  the  free  phosphates,  bladder  mucus, 
infusoria,  and  vaginal  discharges.  Neugebauer  and  Vogel  give  a 
similar  account  of  it,  and  hold  that  it  is  of  no  diagnostic  value.  That 
it  is  of  interest,  as  indicating  the  changes  going  on  in  connection  with 
pregnancy,  is  certain  ;  but  inasmuch  as  it  is  not  of  invariable  occur- 
rence, and  may  even  exist  quite  independently  of  gestation,  it  is 
obviously  quite  undeserving  of  the  extreme  importance  that  has  been 
attached  to  it. 

[Although  not  a  reliable  test  of  pregnancy,  it  is  a  remarkable  fact, 
that  in  all  the  cases  of  suspected  impregnation  in  private  practice  in 
which  I  have  employed  it,  I  never  found  a  woman  pregnant  who  had 
not  shown  it  in  her  urine. — Ed.] 


CHAPTEE   lY. 

SIGNS  AND    SYMPTOMS  OF   PREGNANCY. 

Importance  of  the  Subject. — In  attempting  to  ascertain  the  presence 
or  absence  of  pregnancy,  the  practitioner  has  before  him  a  problem 
which  is  often  beset  with  great  difficulties,  and  on  the  proper  solution 
of  which,  the  moral  character  of  his  patient,  as  well  as  his  own  pro- 
fessional reputation,  may  depend.  The  patient  and  her  friends  can 
hardly  be  expected  to  appreciate  the  fact,  that  it  is  often  far  from 
easy  to  give  a  positive  opinion  on  the  point ;  and  it  is  always  advis- 
able to  use  much  caution  in  the  examination,  and  not  to  commit 
ourselves  to  a  positive  opinion,  except  on  the  most  certain  grounds. 
This  is  all  the  more  important,  because  it  is  just  in  those  cases  in 
which  our  opinion  is  most  frequently  asked,  that  the  statements  of 
the  patient  are  of  least  value,  as  she  is  either  anxious  to  conceal  the 
existence  of  pregnancy,  or,  if  desirous  of  an  affirmative  diagnosis, 


136  PREGNANCY. 

unconsciously  colors  her  statements,  so  as  to  bias  the  judgment  of  the 
examiner. 

Constant  attempts  have  been  made  to  classify  the  signs  of  preg- 
nancy ;  thus  some  divide  them  into  the  natural  and  sensihle  signs, 
others  into  the  presu'mptive^  the  prohahle^  and  the  certain.  The  latter 
classification,  which  is  that  adopted  by  Montgomery  in  his  classical 
work  on  the  "Signs  and  Symptoms  of  Pregnancy,"  is  no  doubt  the 
better  of  the  two,  if  any  be  required.  The  simplest  way  of  studying 
the  subject,  however,  is  the  one,  now  generally  adopted,  of  considering 
the  signs  of  pregnancy  in  the  order  in  which  they  occur,  and  attaching 
to  each  an  estimate  of  its  diagnostic  value. 

Signs  of  a  fruitful  Conception. — From  the  earliest  ages  authors 
have  thought  that  the  occurrence  of  conception  might  be  ascertained 
by  certain  obscure  signs,  such  as  a  peculiar  appearance  of  the  eyes, 
swelling  of  the  neck,  or  by  unusual  sensations  connected  with  a 
fruitful  intercourse.  All  of  these,  it  need  hardly  be  said,  are  far  too 
uncertain  to  be  of  the  slightest  value.  The  last  is  a  symptom  on 
which  many  married  women  profess  themselves  able  to  depend,  and 
one  to  which  Cazeaux  is  inclined  to  attach  some  importance. 

Cessation  of  Menstruation.— The  first  appreciable  indication  of 
pregnancy,  on  which  any  dependence  can  be  placed,  is  the  cessation 
of  the  customary  menstrual  discharge,  and  it  is  of  great  importance, 
as  forming  the  only  reliable  guide  for  calculating  the  probable  period 
of  delivery.  In  women  who  have  been  previously  perfectly  regular, 
in  whom  there  is  no  morbid  cause  which  is  likely  to  have  produced 
suppression,  the  non-appearance  of  the  catamenia  may  be  taken  as 
strong  presumptive  evidence  of  the  existence  of  pregnancy ;  but  it 
can  never  be  more  than  this,  unless  verified  and  strengthened  by 
other  signs,  inasmuch  as  there  are  many  conditions  besides  pregnancy 
which  may  lead  to  its  non-appearance.  Thus  exposure  to  cold, 
mental  emotion,  general  debility,  especially  when  connected  with 
incipient  phthisis,  may  all  have  this  effect.  Mental  impressions  are 
peculiarly  liable  to  mislead  in  this  respect.  It  is  far  from  uncommon 
in  newly-married  women  to  find  that  menstruation  ceases  for  one  or 
more  periods,  either  from  the  general  disturbance  of  the  system  con- 
nected with  the  married  life,  or  from  a  desire  on  the  part  of  the 
patient  to  find  herself  pregnant.  Also  in  unmarried  women,  who 
have  subjected  themselves  to  the  risk  of  impregnation,  mental  emo- 
tion and  alarm  often  produce  the  same  result. 

Menstruation  during  Pregnancy. — A  further  source  of  uncertainty 
exists  in  the  fact,  that  in  certain  cases  menstruation  may  go  on  for 
one  or  more  periods  after  conception,  or  even  during  the  whole 
pregnancy.  The  latter  occurrence  is  certainly  of  extreme  rarity, 
but  one  or  two  instances  are  recorded  by  Perfect,  Churchill,  and 
other  writers  of  authority,  and  therefore  its  possibility  must  be 
admitted,  The  former  is  much  less  uncommon,  and  instances  of  it 
have  probably  come  under  the  observation  of  most  practitioners. 
The  explanation  is  now  well  understood.  During  the  early  months 
of  gestation,  when  the  ovum  is  not  yet  sufficiently  advanced  in  growth 
to  fill  the  whole  uterine  cavity,  there  is  a  considerable  space  between 


SIGNS    AND    SYMPTOMS    OF    PREGNANCY.  137 

the  dccidua  refloxa  which  surrounds  it,  and  the  dccidua  vera  lining 
the  uterine  cavity.  It  is  from  this  free  surface  of  the  dccidua  vera 
that  the  periodical  discharge  comes,  and  there  is  not  only  ample 
surface  for  it  to  come  from,  but  a  free  channel  for  its  escape  through 
the  OS  uteri.  After  the  third  month  the  decidua  reflexa  and  the 
decidua  vera  blend  together,  and  the  space  between  them  disappears. 
Menstruation  after  this  time  is,  therefore,  much  more  difficult  to 
account  for.  It  is  probable  that,  in  many  supposed  cases,  occasional 
losses  of  blood  from  other  sources,  such  as  placenta  praevia,  an  abraded 
cervix  uteri,  or  a  small  polypus,  have  been  mistaken  for  true  men- 
struation. If  the  discharge  really  occurs  periodically  after  the  third 
month,  it  can  only  come  from  the  canal  of  the  cervix.  The  occurrence, 
however,  is  so  rare,  that  if  a  woman  is  menstruating  regularly  and 
normally,  who  believes  herself  to  be  more  than  four  months  advanced 
in  pregnancy,  we  are  justified  ipso  facto  in  negativing  her  supposition. 
In  an  unmarried  woman  all  statements  as  to  regularity  of  menstrua- 
tion are  absolutely  valueless,  for,  in  such  cases,  nothing  is  more 
common  than  for  the  patient  to  make  false  statements  for  the  express 
purpose  of  deception. 

Pregnancy  lolien  Menstruation  is  Normally  Ahsent. — Conception 
may  unquestionably  occur  when  menstruation  is  normally  absent. 
This  is  far  from  uncommon  in  women  during  lactation,  when  the 
function  is  in  abeyance,  and  who  therefore  have  no  reliable  data  for 
calculating  the  true  period  of  their  delivery.  Authentic  cases  are 
also  recorded  in  which  \^oung  girls  have  conceived  before  menstrua- 
tion is  established,  and  in  which  pregnancy  has  occurred  after  the 
change  of  life. 

Estimate  of  its  Diagnostic  Yalne. — Taking  all  these  facts  into  ac- 
count, we  can  only  look  upon  the  cessation  of  menstruation  as  a  fairly 
presumptive  sign  of  pregnancy  in  women  in  whom  there  is  no  clear 
reason  to  account  for  it,  but  one  wdiich  is  undoubtedly  of  great  value 
in  assisting  our  diagnosis. 

Sympathetic  Disturbances. — Shortly  after  conception  various  sym- 
pathetic disturbances  of  the  system  occur,  and  it  is  only  very  excep- 
tionally that  these  are  not  established.  They  are  generally  most 
developed  in  women  of  highly  nervous  temperament;  and  they  are, 
therefore,  most  marked  in  patients  in  the  upper  classes  of  society,  in 
whom  this  class  of  organization  is  most  common. 

Morning  Sickness. — Amongst  the  most  frequent  of  these  are  various 
disorders  of  the  gastro-intestinal  canal.  Nausea  or  vomiting  is  very 
common;  and  as  it  is  generally  felt  on  first  rising  from  the  recum- 
bent position,  it  is  popularly  known  amongst  women  as  the  "  morn- 
ing sickness."  It  sometimes  commences  almost  immediatsly  after 
conception,  but  more  frequently  not  until  the  second  month,  and  it 
rarely  lasts  after  the  fourth  month.  Grenerally  there  is  nausea  rather 
than  actual  vomiting.  The  woman  feels  sick  and  unable  to  eat  her 
breakfast,  and  often  brings  up  some  glairy  fluid.  In  other  cases,  she 
actually  vomits ;  and  sometimes  the  sickness  is  so  excessive  as  to 
resist  all  treatment,  seriously  to  affect  the  patient's  health,  and  even 
10 


138  PREGNANCY. 

imperil  her  life.  These  grave  forms  of  the  affection  will  require 
separate  consideration. 

Cause  of  the  Sickness. — Very  different  opinions  have  been  held  as 
to  the  cause  of  morning  sickness.  Dr.  Henry  Bennet  believes  that, 
when  at  all  severe,  it  is  always  associated  with  congestion  and  inflam- 
mation of  the  cervix  uteri.  Dr.  Graily  Hewitt  maintains  that  it  de- 
pends entirely  on  flexion  of  the  uterus,  producing  irritation  of  the 
uterine  nerves  at  the  seat  of  the  flexion,  and  consequent  sympathetic 
vomiting.  This  theory,  when  broached  at  the  Obstetrical  Society, 
was  received  with  little  favor ;  it  seems  to  me  to  be  sufficiently  dis- 
proved by  the  fact,  which  I  believe  to  be  certain,  that  more  or  less 
nausea  is  a  normal  and  nearly  constant  phenomenon  in  pregnancy, 
for  it  is  difficult  to  believe  that  nearly  every  pregnant  woman  has  a 
flexed  uterus.  The  generally  received  explanation  is,  probably,  the 
correct  one,  viz.,  that  nausea,  as  well  as  other  forms  of  sympathetic 
disturbance,  depends  on  the  stretching  of  the  uterine  fibres  by  the 
growing  ovum,  and  consequent  irritation  of  the  uterine  nerves.  It 
is,  therefore,  one,  and  only  one,  of  the  numerous  reflex  phenomena 
naturally  accompanying  pregnanc3^  It  is  an  old  observation  that 
v^hen  the  sickness  of  pregnancy  is  entirely  absent,  other,  and  gene- 
rally more  distressing,  sympathetic  derangements  are  often  met  with, 
such  as  a  tendency  to  syncope.  Dr.  Eedford^  has  laid  especial  stress 
on  this  point,  and  maintains  that  under  such  circumstances  women 
are  peculiarly  apt  to  miscarry. 

Other  derangements  of  the  dif/estive  functions^  depending  on  the 
same  cause,  are  not  uncommon,  such  as  excessive  or  depraved  appe- 
tite, the  patient  showing  a  craving  for  strange  and  even  disgusting 
articles  of  diet.  These  cravings  may  be  altogether  irresistible,  and 
are  popularly  known  as  "longings."  Of  a  similar  character  is  the 
disturbed  condition  of  the  bowels  frequently  observed,  leading  to 
constipation,  diarrhoea,  and  excessive  flatulence. 

Other  Sympathetic  Phenomena. — Certain  glandular  sympathies  may 
be  developed,  one  of  the  most  common  being  an  excessive  secretion 
from  the  salivary  glands.  A  tendency  to  syncope  is  not  infrequent, 
rarely  proceeding  to  actual  fainting,  but  rather  to  that  sort  of  partial 
syncope,  unattended  with  complete  loss  of  consciousness,  which  the 
older  authors  used  to  call  "lypothemia."  This  often  occurs  in  women 
who  show  no  such  tendency  at  other  times,  and,  when  developed  to 
any  extent,  it  forms  a  very  distressing  accompaniment  of  pregnancy. 
Toothache  is  common,  and  is  not  rarely  associated  with  actual  caries 
of  the  teeth.  When  any  of  these  phenomena  are  carried  to  excess  it 
is  more  than  probable  that  some  morbid  condition  of  the  uterus 
exists,  which  increases  the  local  irritation  producing  them. 

Mental  Peculiarities. — Mental  phenomena  are  \eYj  general.  An 
undue  degree  of  despondency,  utterly  beyond  the  patient's  control, 
is  far  from  uncommon  ;  or  a  change  which  renders  the  bright  and 
good-tempered  woman  fractious  and  irritable  ;  or  even  the  more  for- 
tunate, but  less  common  change,  by  which  a  disagreeable  disposition 
becomes  altered  for  the  better. 

'  Diseases  of  Women  and  CMldren,  p.  551. 


SIGNS    AND    SYMPTOMS    OF    PREGNANCY, 


139 


Diagnostic  Value. — All  these  phenomena  of  exalted  nervous  suscep- 
tibility are  but  of  slight  diagnostic  value.  They  may  be  taken  as 
corroborating  more  certain  signs,  but  nothing  more;  and  they  are 
chiefly  interesting  from  their  tendency  to  be  carried  to  excess  and  to 
])roduce  serious  disorders. 

Mammary  Changes. — Certain  changes  in  the  mammai  are  of  early 
occurrence,  dependent,  no  dcjubt,  on  the  intimate  s^nnpathetic  rela- 
tions at  all  times  existing  between  them  and  the  uterine  organs,  but 
chiefly  required  for  the  purpose  of  preparing  fcjr  the  important  func- 
tion of  lactation,  which,  on  the  termination  of  pregnancy,  thev  have 
to  perform. 

Gha,ntjes  in  the  Areolae. — Generally  about  the  second  month  of  preg- 
nancy the  breasts  become  increased  in  size  and  tender.  As  preg- 
nancy advances  they  become  much  larger  and  firmer,  and  blue  veins 
may  be  seen  coursing  over  them.  The  most  characteristic  changes 
are  about  the  nipples  and  areoke.  The  nipples  become  turgid,  and 
are  frequently  covered  with  minute  branny  scales,  formed  by  the 
desiccation  of  sero-lactescent  fluid  oozing  from  them.  The  areolae  be- 
come greatly  enlarged  and  darkened  from  the  deposit  of  pigment 
(Fig.  75).     The  extent  and  degree  of  this  discoloration  vary  much  in 

Fig.  75. 


Appearance  of  the  Areola  in  Pregnancy. 

different  women.  In  fair  women  it  may  be  so  slight  as  to  be  hardly 
appreciable ;  while  in  dark  women  it  is  generally  exceedingly  charac- 
teristic, sometimes  fonning  a  nearly  black  circle  extending  over  a 
great  part  of  the  breast.  The  areola  becomes  moist  as  well  as  dark 
in  appearance  and  is  somewhat  swollen,  and  a  number  of  small  tuber- 
cles are  developed  upon  it,  forming  a  circle  of  projections  around  the 
nipple.     These  tubercles  are  described  by  Montgomery  as  being inti- 


140  PREGNANCY. 

matelj  connected  with  the  lactiferous  ducts,  some  of  which  may  oc- 
casionally be  traced  into  them  and  seem  to  open  ou  their  summits. 
As  pregnancy  advances  they  increase  in  size  and  number.  During 
the  latter  months  what  has  been  called  "  the  secondary  areola"  is 
produced,  and  when  well  marked  presents  a  very  characteristic  ap- 
pearance. It  consists  of  a  nutnber  of  minute  discolored  spots  all 
round  the  outer  margin  of  the  areola  where  the  pigmentation  is 
fainter,  and  which  are  generally  described  as  resembling  spots  from 
which  the  color  had  been  discharged  by  a  shower  of  water-drops. 
This  change,  like  the  darkening  of  the  primary  areola,  is  most  marked 
in  brunettes.  At  this  period,  especially  in  women  whose  skin  is  of 
fine  texture,  whitish  silvery  streaks  are  often  seen  on  the  breasts. 
They  are  produced  by  the  stretching  of  the  cutis  vera,  and  are  per- 
manent. 

By  pressure  on  the  breasts  a  small  drop  of  serous-looking  fluid 
can  very  generally  be  pressed  out  from  the  nipple  often  as  early  as 
the  third  month,  and  on  microscopic  examination  milk  and  cholos- 
trum  globules  can  be  seen  in  it. 

Dicujnoatic  Value  of  Mammary  Changes. — The  diagnostic  value  of 
these  mammary  changes  has  been  variously  estimated.  A¥hen  well 
marked  they  are  considered  by  Montgomery  to  be  certain  signs  of 
pregnancy.  To  this  statement,  however,  some  important  limitations 
must  be  made.  In  women  who  have  never  borne  children  they,  no 
doubt,  are  so ;  for,  although  various  uterine  and  ovarian  diseases 
produce  some  darkening  of  the  areola,  they  certainly  never  produce 
the  well-marked  changes  above  described.  In  multiparge,  however, 
the  areolae  often  remain  permanently  darkened,  and  in  them  these 
signs  are  much  less  reliable.  In  lirst  pregnancies  the  presence  of 
milk  in  the  breasts  may  be  considered  an  almost  certain  sign,  and  it 
is  one  which  I  have  rarely  failed  to  detect  even  from  a  comparatively 
early  period.  It  is  true  that  there  are  authenticated  instances  of 
non-pregnant  women  having  an  abundant  secretion  of  milk  estab- 
lished from  mammary  irritation.  Thus  Baudelocque  presented  to 
the  Academy  of  Surgery  of  Paris  a  young  girl,  eight  years  of  age, 
who  had  nursed  her  little  brother  for  more  than  a  month.  Dr.  Tan- 
i.er  states — I  do  not  know  on  what  authority — that  "it  is  not  uncom- 
mon in  Western  Africa  for  young  girls  who  have  never  been  preg- 
nant to  regularly  employ  themselves  in  nursing  the  children  of  others, 
the  mammge  being  excited  to  action  by  the  application  of  the  juice 
of  (me  of  the  euphorbiaceaa."  Lacteal  secretion  has  even  been  noticed 
in  the  male  breast.  But  these  exceptions  to  the  general  rule  are  so 
uncommon  as  merely  to  deserve  mention  as  curiosities ;  and  I  have 
almost  never  been  deceived  in  diagnosing  a  first  pregnancy  from  the 
presence  of  even  the  minutest  quantity  of  lacteal  secretion  in  the 
breasts,  although  even  then  other  corroborative  signs  should  always 
be  sought  for.  In  multiparge  the  presence  of  milk  is  by  no  means 
so  valuable,  for  it  is  common  for  milk  to  remain  in  the  mammse  long 
after  the  cessation  of  lactation,  even  for  several  years.  Tyler  Smith 
correctly  savs  that  "suppression  of  the  milk  in  persons  who  are 
nursing  and  liable  to  impregnation  is  a  more  valuable  sign  of  preg- 


SIGNS    AND    SYMPTOMS    OF    PREGNANCY.  141 

nancy  than  the  converse  condition."     This  is  an  observation  I  have 
frequently  corroborated. 

As  a  diagnostic  sign,  therefore,  the  mammar}'  a])pcarances  are  of 
great  importance  in  primiparie,  and  when  well  marked  they  are  sel- 
dom likely  to  deceive.  They  are  specially  important  when  we  sus- 
pect pregnancy  in  the  unmarried,  as  we  can  easily  make  an  excuse 
to  look  at  the  breast  without  explaining  to  the  patient  the  reason  ; 
and  a  single  glance,  especially  if  the  patient  be  dark-complexioned, 
may  so  far  strengthen  our  suspicion  as  to  justify  a  more  thorough 
examination.  In  married  multipara)  they  ai'e  less  to  be  depended 
upon. 

Olher  Pigmentary  Changes. — In  connectioii  with  this  subject  may 
be  mentioned  various  irregular  deposits  of  pigment  Avhich  are  fre- 
quently observed.  The  most  common  is  a  dark-brownish  or  yellow- 
ish line  starting  from  the  pubes  and  running  up  to  the  centre  of  the 
abdomen,  sometimes  as  far  as  the  umbilicus  only,  at  others  forming 
an  irregular  ring  round  the  umbilicus,  and  reaching  to  the  epigas- 
trium. [It  is  well  marked  in  pregnant  women  of  the  African  race, 
even  in  those  of  quite  a  dark  shade  of  skin.  This  line  is  narrower 
as  a  rule,  than  in  the  white,  but  darker. — Ed.]  It  is,  however,  of 
very  uncertain  occurrence,  being  well  marked  in  some  women,  while 
in  others  it  is  entirely  absent.  Patches  of  darkened  skin  are  often 
observed  about  the  face,  chiefly  on  the  forehead,  and  this  bronzing 
sometimes  gives  a  very  peculiar  appearance.  Joulin  states  that  it 
only  occurs  on  parts  of  the  face  exposed  to  the  sun,  and  that  it  is 
therefore  most  frequently  observed  in  women  of  the  lower  order  who 
are  freely  exposed  to  atmospheric  influences.  These  pigmentary 
changes  are  of  small  diagnostic  value,  and  may  continue  for  a  con- 
siderable time  after  delivery. 

Enlargement  of  the  Abdomen. — The  progressive  enlargement  of  the 
abdomen,  and  tlie  size  of  the  gravid  uterus  at  various  periods  of 
pregnancy,  as  well  as  the  method  of  examination  by  means  of  ab- 
dominal palpation,  have  already  been  described  (pp.  il6  and  126). 

We  will  now  consider  the  well-known  phenomena  produced  by 
the  movements  of  the  foetus  in  utero,  which  are  so  familiar  to  all 
pregnant  women.  These,  no  doubt,  take  place  from  the  earliest 
period  of  foetal  life  at  which  the  muscular  tissue  of  the  foetus  is  suffi- 
ciently developed  to  admit  of  contraction,  but  the}-  are  not  felt  by 
the  mother  until  somewhere  about  the  sixteenth  week  of  utero-ges- 
tation,  the  precise  period  at  which  they  are  perceived  varying  con- 
siderably in  different  cases.  The  error  of  the  law  on  this  subject, 
which  supposes  the  child  not  to  be  alive,  or  "quick,"  until  the  mother 
feels  its  movements,  is  well  known,  and  has  frequently  been  protested 
against  by  the  medical  profession.  The  so-called  quickening — which 
certainly  is  felt  very  suddenly  by  some  women — is  believed  to  depend 
on  the  rising  of  the  uterine  tumor  sufficiently  high  to  permit  of  the 
impulse  of  the  foetus  being  transmitted  to  the  abdominal  walls  of  the 
mother,  through  the  sensory  nerves  of  which  its  movements  become 
appreciable.  The  sensation  is  generally  described  as  being  a  feeble 
fluttering,  which,  when  first  felt,  not  unfrequently  causes,  unpleasant 


142  PREGNANCY. 

nervous  sensations.  As  the  uterus  enlarges,  the  movements  become 
more  and  more  distinct,  and  generally  consist  of  a  series  of  sharj) 
blows  or  kicks,  sometimes  quite  appreciable  to  the  naked  eye,  and 
causing  distinct  projections  of  the  abdominal  walls.  Their  force  and 
frequency  will  also  vary  during  pregnancy  according  to  circum- 
stances. At  times  they  are  very  frequent  and  distressing;  at  others, 
the  foetus  seems  to  be  comparatively  quiet,  and  they  may  even  not 
be  felt  for  several  days  in  succession,  and  thus  unnecessary  fears  as 
to  the  death  of  the  foetus  often  arise.  The  state  of  the  mother's 
health  has  an  undoubted  influence  upon  them.  They  are  said  to 
increase  in  force  after  a  prolonged  abstinence  from  food,  or  in  certain 
positions  of  the  body.  It  is  certain  that  causes  interfering  with  the 
vitality  of  the  foetus  often  produce  very  irregular  and  tumultuous 
movements.  They  can.  be  very  readily  felt  by  the  accoucheur  on 
palpating  the  abdomen,  and  sometimes,  in  the  latter  months,  so  dis- 
tinctly as  to  leave  no  doubt  as  to  the  existence  of  pregnancy.  They 
can  also  generally  be  induced  by  placing  one  hand  on  each  side  of 
the  abdomen  and  applying  gentle  pressure,  which  will  induce  fecial 
motion,  that  can  be  easily  appreciated. 

Tlie  Diagnostic  Value  of  Foetal  Movements.- — -As  a  diagnostic  sign 
the  existence  of  foetal  movements  has  always  held  a  high  place,  but 
care  should  be  taken  in  relying  on  it.  It  is  certain  that  women  are 
themselves  yqtj  often  in  error,  and  fancy  they  feel  the  movements 
of  a  foetus  when  none  exists,  being  probably  deceived  by  irregular 
contractions  of  the  abdominal  muscles,  or  flatus  within  the  bowels. 
They  may  even  involuntarily  produce  such  intra-abdominal  move- 
ments as  may  readily  deceive  the  practitioner.  Of  course,  in  advanced 
pregnancy,  when  the  foetal  movements  are  so  marked  as  lo  be  seen  as 
well  as  felt,  a  mistake  is  hardly  possible,  and  they  then  constitute  a 
certain  sign.  But  in  such  cases  there  is  an  abundance  of  other  indi- 
cations and  little  room  for  doubt.  In  questionable  cases,  and  at  an 
earlier  period  of  pi'egnancy,  the  fact  that  movements  are  not  felt 
must  not  be  taken  as  a  proof  of  the  non-existence  of  pregnancy,  for 
they  may  be  so  feeble  as  not  to  be  perceptible,  or  they  may  be  absent 
for  a  considerable  period. 

Intermittent  Uterine  Contractions. — Braxton  Ilicks^  has  directed 
attention  to  the  value,  from  a  diagnostic  point  of  view,  of  intermittent 
contractions  of  the  uterus  during  pregnancy.  After  the  uterus  is 
sufficiently  large  to  be  felt  by  ])alpation,  if  the  hand  be  placed  over 
it,  and  be  grasped  for  a  time  without  using  any  friction  or  pressure, 
it  will  be  observed  to  distinctly  harden  in  a  manner  that  is  quite 
characteristic.  This  intermittent  contraction  occurs  every  five  or  ten 
minutes,  sometimes  oftener,  rarely  at  longer  intervals.  The  fact  that 
the  uterus  did  contract  in  this  way  had  been  previously  described, 
more  ecpeciallv  by  Tyler  Smith,  who  ascribed  it  to  peristaltic  action. 
But  it  is  certain  that  no  one,  before  Dr.  Hicks,  had  pointed  out  the 
fact  that  such  contractions  were  constant  and  normal  concomitants 
of  pregnancy,  continuing  during  the  whole  period  of  utero-gestation, 

1  Obst.  Trans,  v.  13. 


SIGNS    AND    SYMPTOMS    OF    PREGNANCY.  lAt 

and  forming  a  ready  and  reliable  means  of  distinguishing  tlic  uterine 
tumor  from  other  abdominal  enlargements.  Since  reading  Dr.  Ilicks's 
paper  I  have  paid  considerable  attention  to  this  sign,  which  I  have 
never  failed  to  detect,  even  in  the  retroverted  gravid  uterus  contained 
entirely  in  the  pelvic  cavity,  and  I  am  disposed  entirely  to  agree 
with  him  as  to  its  great  value  in  diagnosis.  If  the  hand  be  kept 
steadily  on  the  uterus,  its  alternate  hardening  and  relaxation  can  be 
appreciated  with  the  greatest  ease.  The  advantages  which  this  sign 
has  over  the  foetal  movements  are  that  it  is  constant,  that  it  is  not 
liable  to  be  simulated  by  anything  else,  and  that  it  is  independent  of 
the  life  of  the  child,  being  equally  appreciable  when  the  uterus  con- 
tains a  degenerated  ovum  or  dead  foetus.  The  only  condition  likely 
to  give  rise  to  error  is  an  enlargement  of  the  uterus  in  consequence 
of  contents  other  than  the  results  of  conception,  such  as  retained 
menses,  or  a  polypus.  The  history  of  such  cases — which  are  more- 
over of  extreme  rarity — would  easily  prevent  any  mistake.  As  a 
corroborative  sign  of  pregnancy,  therefore,  I  should  give  these  inter- 
mittent contractions  a  high  place.  [I  once  attended  the  wife  of  a 
physician  in  her  second  pregnancy,  who  had  lost  her  first  child  by 
abortion,  and  was  supposed  to  be  again  threatened  with  the  same 
misfortune.  I  found  her  suffering  pain  with  each  intermittent  con- 
traction, but  beyond  this,  there  were  no  symptoms  to  indicate  an  ex- 
pulsive design  on  the  part  of  the  uterus.  These  2^cnn/idinterm[ttent 
contractions  persisted  for  three  weeks,  and  then  gradually  assumed 
their  normal  character  under  an  opiate  treatment.  The  lady  went 
to  the  full  term  of  gestation  and  bore  a  child  which  lived. — Ed.] 

Vac/L7ial  Signs  of  Pregnancy. — The  vaginal  signs  of  pregnancy 
are  of  considerable  importance  in  diagnosis.  They  are  chiefly  the 
changes  which  may  be  detected  in  the  cervix,  and  the  so-called  hal- 
lottement^  which  depends  on  the  mobility  of  the  foetus  in  the  liquor 
amnii.    _ 

Softening  of  the  Cervix. — -The  alterations  in  the  density  and  appa- 
rent length  of  the  cervix  have  been  already  described  (p.  12S). 
When  pregnancy  has  advanced  beyond  the  fifth  month  the  peculiar 
velvety  softness  of  the  cervix  is  very  characteristic,  and  affords  a 
strons:  corroborative  sia:n,  but  one  which  it  would  be  unsafe  to  rely 
on  by  itself,  inasmuch  as  very  similar  alterations  may  be  produced 
by  various  causes.  When,  however,  in  a  supposed  case  of  preg- 
nancy advanced  beyond  the  period  indicated,  the  cervix  is  found  to 
be  elongated,  dense,  and  projecting  into  the  vaginal  canal,  the  non- 
existence of  pregnancy  may  be  safely  inferred.  Therefore  the  nega- 
tive value  of  this  sign  is  of  more  importance  than  the  positive. 
.  Ballotiemeyit^  when  distinctly  made  out,  is  a  very  valuable  indica- 
tion of  yjregnancy.  It  consists  in  the  displacement,  by  the  examin- 
ing finger,  of  the  foetus,  which  floats  up  in  the  liquor  amnii,  and 
falls  back  again  on  the  tip  of  the  finger  with  a  slight  tap  which  is 
exceedingly  characteristic. 

Method  of  Examination. — In  order  to  practise  it  most  easily,  the 
])atient  is  placed  on  a  couch  or  bed  in  a  position  midway  between 
sitting  and   lying,    by   which   the  vertical   diameter   of  the  uterine 


144  PREGNANCY. 

cavity  is  brought  into  correspondence  with  that  of  the  pelvis.  Two 
fingers  of  the  right  hand  are  then  passed  high  up  into  the  vagina  in 
front  of  the  cervix.  The  uterus  being  now  steadied  from  without 
by  tlie  left  hand,  the  intravaginal  fingers  press  the  uterine  wall 
suddenly  upwards,  when,  if  pregnancy  exist,  the  foetus  is  displaced, 
and  in  a  moment  falls  back  again,  imparting  a  distinct  impulse  to 
the  fingers.  When  easily  appreciable  it  may  be  considered  as  a 
certain  sign,  for  although  an  ante- flexed  fundus,  or  a  calculus  in  the 
bladder,  may  give  rise  to  somewhat  similar  sensations,  the  absence 
of  other  indications  of  pregnancy  would  readily  prevent  error.  Bal- 
lottement  is  practised  between  the  fourth  and  seventh  months.  Be- 
fore the  former  time  the  foetus  is  too  small,  while  at  a  later  period 
it  is  relatively  too  large,  and  can  no  longer  be  easily  made  to  rise 
upwards  in  the  surrounding  liquor  amnii.  The  absence  of  ballotte- 
ment  must  not  be  taken  as  proving  the  non-existence  of  pregnancv, 
for  it  may  be  inappreciable  from  a  variety  of  causes,  such  as  abnor- 
mal presentations,  or  the  implantation  of  the  placenta  upon  the 
cervix  uteri. 

Vaginal  Pulsation. — There  are  also  some  other  vaginal  signs  of 
pregnancy  of  secondary  consequence.  Amongst  these  is  the  vaginal 
pulsation,  pointed  out  by  Osiander,  resulting  from  the  enlargement 
of  the  vaginal  arteries,  which  ma}"  sometimes  be  felt  beating  at  an 
early  period.  Often  this  pulsation  is  very  distinct,  at  other  times  it 
cannot  be  felt  at  all,  and  it  is  altogether  unreliable,  as  a  similar  pul- 
sation xnsij  be  felt  in  various  uterine  diseases. 

Uterine  Fluctuation. — Dr.  Easch  has  drawn  attention  to  a  pre- 
viously nndescribed  sign  which  he  believes  to  be  of  importance  in 
the  diagnosis  of  early  pregnancy.^  It  consists  in  the  detection  of 
fluctuation  through  the  anterior  uterine  wall,  depending  on  the  pres- 
ence of  the  liquor  amnii.  In  order  to  make  this  out,  two  fingers  of 
the  right  hand  must  be  used,  as  in  ballottement,  while  the  uterus  is 
steadied  through  the  abdomen.  Dr  Easch  states  that  by  this  means 
the  enlarged  uterus  in  pregnancy  can  easily  be  distinguished  from 
the  enlargement  depending  on  other  causes,  and  that  fluctuation  can 
always  be  felt  as  early  as  the  second  month.  If  it  is  associated  Avith 
suppressed  menstruation  and  darkened  areolae,  he  considers  it  a  cer- 
tain sign.  In  order  to  detect  it,  however,  considerable  experience 
in  making  vaginal  examinations  is  essential,  and  it  can  liaidly  be 
depended  on  for  general  use. 

Alteration  in  Color  of  'he  Yagina. — A  peculiar  deep  violet  hue  of 
the  vaginal  mucous  membrane  Avas  relied  on  by  Jacquemier  and 
Kllige  as  affording  a  readily-observed  indication  of  pregnancy.  In 
most  cases  it  is  Avell  marked ;  sometimes,  indeed,  the  change  of  color 
is  very  intense,  and  it  evidently  depends  on  the  congestion  produced 
by  pressure  of  the  enlarged  uterus.  The  same  effect,  however,  is 
constantly  seen  where  similar  pressure  is  affected  by  large  fibroid 
tumors  of  the  uterus,  and,  therefore,  for  diagnostic  purposes  it  is 
valueless, 

'  Brit.  Med.  Journ..  vol.  ii.  1873. 


SIGNS    AND    SYMPTOMS    OF    PREGNANCY.  145 

Auscultatory  Signs  of  Pregnancy. — By  far  the  most  important 
signs  are  those  which  can  be  detected  by  abdominal  auscultation, 
and  one  of  these — the  hearing  of  the  foetal  heart-sounds — forms 
the  only  sign  which  per  se,  and  in  the  absence  of  all  others,  is  per- 
fectly reliable. 

Discovery  of  Foetal' AiiscuUalion. — The  fact  that  the  sounds  of  the 
foetal  heart  are  audible  during  advanced  pregnancy  was  first  pointed 
out  by  Mayor  of  Geneva  in  1818,  and  the  main  facts  in  connection 
with  foetal  auscultation  were  subsequently  worked  out  by  Kerga- 
radec,  ISTaegele,  Evory  Kennedy,  and  other  observers.  The  pulsations 
first  become  audible,  as  a  rule,  in  the  course  of  the  fifth  month,  or 
about  the  middle  of  the  fourth  month.  In  exceptional  circumstances, 
and  by  practised  observers,  they  have  been  heard  earlier.  Depaul 
believes  that  he  detected  them  as  early  as  the  eleventh  week,  and 
Routh  has  also  detected  them  at  an  early  period  by  vaginal  stetho- 
scopy,  which,  however,  for  obvious  reasons,  cannot  be  ordinarily 
employed.  Naegele  never  heard  them  before  the  eighteenth  week, 
more  generally  at  the  end  of  the  twentieth,  and  for  practical  purposes 
the  pregnancy  must  be  advanced  to  the  fifth  month  before  we  can 
reasonably  expect  to  detect  them.  From  this  period  up  to  term  they 
can  almost  always  be  heard,  if  not  at  the  first  attempt,  at  least  after- 
wards, to  a  certainty,  if  Ave  have  the  opportunity  of  making  repeated 
examinations.  Accidental  circumstances,  such  as  the  presence  of  an 
unusual  amount  of  flatus  in  the  intestines,  may  deaden  the  sounds  for 
a  time,  but  not  permanently.  Depaul  only  failed  to  hear  them  in  8 
cases  out  of  906  examined  during  the  last  three  months  of  pregnancy ; 
and  out  of  180  cases,  which  Dr.  Anderson  of  Grlasgow  carefully  ex- 
amined, he  only  failed  in  12,  and  in  each  of  these  the  child  was  still- 
born. They,  therefore,  form  not  only  a  most  certain  indication  of 
pregnancy,  but  of  the  life  of  the  foetus  also. 

Description  of  the  Sound. — -The  sound  has  been  always  likened  to 
the  double  tic-tac  of  a  watch  heard  through  a  pillow,  which  it  closely 
resembles.  It  consists  of  two  beats,  separated  by  a  short  interval, 
the  first  being  the  loudest  and  most  distinct,  the  second  being  some- 
times inaudible.  The  rapidity  of  the  foetal  pulsations  forms  an 
important  means  of  distinguishing  them  from  transmitted  maternal 
pulsations,  with  which  they  might  be  confounded.  Their  average 
number  is  stated  by  Slater,  who  made  nnmerous  observations  on  this 
point,  to  be  132,  but  sometimes  they  reach  as  high  as  140,  and  some- 
times as  low  as  120.  It  will  thus  be  seen  that  the  pulsations  are 
always  much  more  rapid  than  those  of  the  mother's  heart,  unless, 
indeed,  the  latter  be  unduly  accelerated  by  transient  mental  emotion 
or  disease.  To  avoid  mistakes,  whenever  the  foetal  heart  is  heard 
its  rate  of  pulsation  should  be  carefully  counted,  and  compared  with 
that  of  the  mother's  pulse;  if  the  rate  differ,  we  may  be  sure  that 
no  error  has  been  made.  The  rapidity  of  the  foetal  pulsations,  re- 
mains, as  a  rule,  the  same  during  the  whole  period  of  pregnancy, 
while  their  intensity  gradually  increases.  They  may,  however,  be 
temporarily  increased  or  diminished  in  frequency  by  disturbing 
causes,   such  as   the    pressure  of  the   stethoscope,  which,   exciting 


146  PREGNANCY. 

tumultuous  movements  of  the  foetus,  may  induce  greatly-increased 
frequency  of  its  heart- beats.  So  also  during  labor,  after  the  escape 
of  the  liquor  amnii,  when  the  contractions  of  the  uterus  have  a  very 
distinct  influence  on  the  foetus,  they  may  be  greatly  modified.  An 
acceleration  or  irregularity  of  the  pulsations,  made  out  in  the  course 
of  a  prolonged  labor,  may  thus  be  of  great  practical  importance,  by 
indicating  the  necessity  for  prompt  interference.  Similar  alterations, 
associated  with  tumultuous  and  unusual  foetal  movements  felt  by  the 
mother  towards  the  end  of  pregnancy,  may  point  to  danger  to  the 
life  of  the  foetus  during  the  latter  months,  and  may  even  justify  the 
induction  of  premature  labor.  This  is  especially  the  case  in  women 
who  have  previously  given  birth  to  a  succession  of  dead  children 
owing  to  disease  of  the  placenta,  and,  in  them,  careful  and  frequently 
repeated  auscultations  may  warn  us  of  the  impending  danger. 

Supposed  difference  of  Rapidity  according  to  the  Sex  of  the  Foetus. — 
The  rapidity  of  the  foetal  heart  has  been  supposed  by  some  to  afford 
a  means  of  determining  the  sex  of  the  child  before  birth.  Franken- 
hauser,  who  first  directed  attention  to  this  point,  is  of  opinion  that 
the  average  rate  of  pulsations  of  the  heart  is  considerably  less  in 
male  than  in  female  children,  averaging  124  in  the  minute  in  the 
former,  as  against  144  in  the  latter.  Steinbach  makes  the  difference 
somewhat  less,  viz.,  131  for  males,  and  138  for  females.  He  pre- 
dicted the  sex  correctly  by  this  means  in  46  out  of  57  cases,  while 
Frankenhauser  was  correct  in  the  whole  50  cases  which  he  specially 
examined  with  reference  to  the  point.  Dr.  Hutton,  of  New  York,^ 
was  also  connect  in  7  cases  he  fixed  on  for  trial.  Devilliers  found 
the  difference  in  the  sexes  to  be  the  same  as  Steinbach  ;  he  attributes 
it,  however,  to  the  size  and  weight,  rather  than  to  the  sex  of  the 
child,  and  believes  the  pulsations  to  be  least  numerous  in  large  and 
well-developed  children.  As  male  children  are  usually  larger  than 
female,  he  thus  explains  the  relatively  less  frequent  pulsations  of 
their  hearts.  Dr.  Gumming,  of  Edinburgh,  also  believes  that  the 
weight  of  the  child  has  considerable  influence  on  the  frequency  of 
its  cardiac  pulsations,  so  that  a  large  female  child  may  have  a  slower 
pulse  than  a  small  male.^  The  point,  however  is  more  curious  than 
practical,  and  the  rapidity  of  the  pulsations  certainly  Avould  not 
justify  any  positive  prediction  on  the  subject.  Circumstances  in- 
fluencing the  maternal  circulation  seem  to  have  no  influence  on  that 
of  the  foetus. 

Site  at  ichich  the  Sounds  are  heard. — The  foetal  heart-sounds  are 
generally  propagated  best  by  the  back  of  the  child,  and  are,  there- 
fore, most  easily  audible  when  this  is  in  contact  with  the  anterior 
wall  of  the  uterus,  as  is  the  case  in  the  large  majority  of  pregnancies. 
When  the  child  is  placed  in  the  dorso-posterior  position,  the  sounds 
have  to  traverse  a  larger  amount  of  the  liquor  amnii,  and  are  further 
modified  by  the  interposition  of  the  foetal  limbs.  They  are,  there- 
fore, less  easily  heard  in  such  cases,  but  even  in  them  they  can  almost 
always  be  made  out.     As  the  foetus  most  frequently  lies  with  the 

'  New  York  Med.  Jourii.,  July,  1872.  2  Edin.  Med.  Jouni.,  1875. 


SIGNS    AND    SYMPTOMS    OF    PREGNANCY.  14*7 

occiput  over  the  brim  of  the  23clvis,  and  the  back  of  the  child  towards 
the  left  side  of  the  mother,  the  heart-sounds  are  iisually  most  dis 
tinctly  audible  at  a  point  midway  between  the  umbilicus  and  the  left 
anterior  superior  spine  of  the  ilium.  In  the  next  most  common  posi- 
tion, in  which  the  back  of  the  child  lies  to  the  right  lumbar  region 
of  the  mother,  they  are  generally  heard  at  a  corresponding  point  at 
the  right  side,  but  in  this  case  they  are  frequently  more  readily  made 
out  in  the  right  flank,  being  then  transmitted  through  the  thorax  of 
the  child,  which  is  in  contact  with  the  side  of  the  uterus.  In  breech 
cases,  on  the  other  hand,  the  heart-sounds  are  generally  heard  most 
distinctly  above  the  umbilicus,  and  either  to  the  right  or  left,  accord- 
ing to  the  side  towards  whicli  the  back  of  the  child  is  jjlaced.  It 
will  thus  be  seen  that  the  place  at  which  the  foetal  heart-rounds  are 
heard  varies  with  the  position  of  the  foetus;  and  this,  when  combined 
with  the  information  derived  from  palpation,  affords  a  ready  means 
of  ascertaining  the  presentation  of  the  child  before  labor.  The  sounds 
are  only  audible  over  a  limited  space,  about  two  to  three  inches  in 
diameter ;  therefore,  if  we  fail  to  detect  them  in  one  place,  a  careful 
exploration  of  the  whole  uterine  tumor  is  necessary  before  we  are 
satisfied  that  they  cannot  bo  heard. 

Sources  of  Fallacy. — The  only  mistake  that  is  likely  to  be  made  is 
taking  the  maternal  pulsations,  transmitted  through  the  uterine 
tumor,  for  those  of  the  foetal  heart.  A  little  care  will  easily  prevent 
this  error,  and  the  frequency  of  the  mother's  ]:)ulse  should  always  be 
ascertained  before  counting  the  supposed  foetal  pulsations.  If  these 
are  found  to  be  120  or  more,  while  the  mother's  pulse  is  only  70  or  80, 
no  mistake  is  possible.  If  the  latter  is  abnormally  quickened  greater 
care  may  be  necessary,  but  even  then  the  rate  of  pulsation  of  each 
will  be  dissimilar,  Braxton  Hicks'  has  pointed  out  that  in  tedious 
labor,  when  the  muscular  powers  of  the  mother  are  exhausted,  the 
muscular  subsurrus  may  produce  a  sound  closely  resembling  the  foetal 
pulsation ;  but  error  from  this  source  is  obviously  very  improbable. 

Mode  of  'practising  Auscultation. — In  listening  for  the  fcetal  heart- 
sound  the  patient  should  be  placed  on  her  back,  with  the  shoulders 
elevated  and  the  knees  flexed.  The  surface  of  the  abdomen  should 
be  uncovered,  and  an  ordinary  stethoscope  employed,  the  end  of 
which  must  be  pressed  firmly  on  the  tumor,  so  as  to  depress  the  ab- 
dominal walls.  The  most  absolute  stillness  is  necessary,  as  it  is  often 
far  from  easy  to  hear  the  sounds.  Sometimes,  after  failing  with  the 
ordinary  stethoscope,  I  have  succeeded  with  the  bin-aural,  which  re- 
markably intensifies  them.  When  once  heard  they  are  most  easily 
counted  during  a  space  of  five  seconds,  as,  on  account  of  their  frequency, 
it  is  not  always  possible  to  follow  them  over  a  longer  period.  [The 
double  stethoscope  in  use  in  the  United  States  is  the  invention  of  the 
late  Dr.  G.  P.  Gammann,  of  New  York,  a  celebrated  and  ingenious  physi- 
cian who  devoted  his  life  to  the  study  of  the  diseases  of  the  chest, — Ed.] 

Value  of  this  Sign  of  Pregnancy. — When  the  foetal  heart-sounds 
are  heard  distinctly,  pregnancy  may  be  absolutely  and  certainly  diag- 

'  Obst.  Trans.,  vol.  xv. 


148  TREGNANCY. 

nosed.  The  fact  that  we  do  not  hear  them  does  not,  however,  pre- 
clude the  possibility  of  gestation,  for  the  foetus  may  be  dead,  or  the 
sounds  temporarily  inaudible. 

Umbilical  Souffle. — There  are  some  other  sounds  heard  in  ausculta 
tion  which  are  of  very  secondary  diagnostic  value.  One  of  these  is 
the  so-called  umbilical  orfvMic  souffle,  which  was  first  pointed  out  by 
Evory  Kennedy.  It  consists  of  a  single  blowing  murmur,  synchro- 
nous with  the  foetal  heart-sounds,  and  most  distinctly  heard  in  the 
immediate  vicinity  of  the  point  where  these  are  most  audible.  Most 
authors  believe  it  to  be  produced  by  pressure  on  the  cord,  either 
when  it  is  placed  between  a  hard  part  of  the  foetus  and  the  uterine 
walls,  or  is  twisted  round  the  child's  neck.  Schroeder  and  Hecker 
detected  it  in  fourteen  or  fifteen  per  cent,  of  all  cases,  and  the  latter 
believed  it  to  be  caused  by  flexure  of  the  first  portion  of  the  cord 
near  the  umbilicus.  For  practical  purposes  it  is  quite  valueless,  and 
need  only  be  mentioned  as  a  phenomenon  which  an  experienced  aus- 
cultator  may  occasionally  detect. 

Uterine  Souffle. — -The  uterine  souffle  is  a  peculiar  single  whizzing 
murmur  which  is  almost  always  audible  on  auscultation.  It  varies 
very  remarkably  in  character  and  position.  Sometimes  it  is  a  gentle 
blowing  or  even  musical  murmur;  at  others  it  is  loud,  harsh,  and  scrap- 
ing ;  sometimes  continuous,  sometimes  intermittent.  It  may  also  be 
heard  at  any  point  of  the  uterus,  but  most  frequently  low  down,  and  to 
one  or  other  side ;  more  rarely  above  the  umbilicus,  or  towards  the  fun- 
dus ;  and  it  often  changes  its  position  so  as  to  be  heard  at  a  subsequent 
auscultation  at  a  point  where  it  was  previously  inaudible.  It  may 
be  heard  over  a  space  of  an  inch  or  two  only,  or  in  some  cases,  over 
the  whole  uterine  tumor;  or  again,  it  may  sometimes  be  detected 
simultaneously  over  two  entirely  distinct  portions  of  the  uterus.  It 
is  generally  to  be  heard  earlier  than  the  foetal  heart-sounds,  often  as 
soon  as  the  uterus  rises  above  the  brim  of  the  pelvis,  and  it  can  almost 
always  be  detected  after  the  commencement  of  the  fourth  month. 
The  sound  becomes  curiously  modified  by  the  uterine  contractions 
during  labor,  becoming  louder  and  more  intense  before  the  pain  comes 
on,  disappearing  during  its  acme,  and  again  being  heard  as  it  goes 
of!:'.  Hicks  attributes  to  a  similar  cause,  viz.,  the  uterine  contractions 
during  pregnancy,  the  frequent  variations  in  the  sound  which  are 
characteristic  of  it.'  The  uterine  soufile  is  also  audible  after  lhe 
death  of  the  fcetus,  and  it  is  believed  by  some  to  be  modified  and  to 
become  more  continuously  harsh  when  that  event  has  taken  place. 

Theories  as  to  its  Cause.' — -Very  various  explanations  have  been 
given  of  the  causes  of  this  sound.  For  long  it  was  supposed  to  be 
formed  in  the  vessels  of  the  placenta,  and  hence  the  name  ^^ placental 
souffle,''''  by  which  it  is  often  talked  of;  or  if  not  in  the  placenta,  in 
the  uterine  vessels  in  its  immediate  neighborhood.  The  non-placental 
origin  of  the  sound  is  sufficiently  demonstrated  by  the  fact  that  it 
may  be  heard  for  a  considerable  time  after  the  expulsion  of  the  pla- 
centa.   Some  have  supposed  that  it  is  not  formed  in  the  uterus  at  all, 

1  Op.  cit.  p.  233. 


SIGNS    AND    SYMPTOMS    OF    PREGNANCY.  _     149 

but  ill  the  maternal  vessels,  especially  the  aorta  and  the  iliac  arteries, 
owing  to  the  pressure  to  which  they  are  subjected  by  the  gravid 
uterus.  The  extreme  irregularity  of  the  sound,  its  occasional  disap- 
pearance, and  its  variable  site,  seem  to  be  conclusive  against  this 
view.  The  theory  which  refers  the  sound  to  the  uterine  vessels  is 
that  which  has  received  most  adherents,  and  which  best  meets  the 
facts  of  the  case ;  but  it  is  by  no  means  easy  or  even  possible  to 
account  for  the  exact  mode  of  its  production  in  them.  Each  of  the 
ex[jlanations  which  have  been  given  is  open  to  some  objection.  It 
is  far  from  unlikely  that  the  intermittent  contractions  of  the  uterine 
fibres,  which  are  known  to  occur  daring  the  whole  course  of  preg- 
nancy, may  have  much  to  do  with  it,  by  modifying,  at  intervals,  the 
rapidity  of  the  circulation  in  the  vessels.  Its  production  in  this 
manner  may  also  be  favored  by  the  chlorotic  state  of  the  blood,  to 
which  Cazeaux  and  Scanzoni  are  inclined  to  attribute  an  important 
influence,  likening  it  to  the  antemic  murmur  so  frequently  heard  in 
the  vessels  in  weakly  women. 

Dia'jnostic  Value. — From  a  diagnostic  point  of  view  the  uterine 
souffle  is  of  very  secondary  importance,  because  a  similar  sound  is 
very  generally  audible  in  large  fibroid  tumors  of  the  uterus,  and 
even  in  some  few  ovarian  tumors ;  it  is,  therefore,  of  little  or  no 
value  in  assisting  us  to  decide  the  character  of  the  abdominal  enlarge- 
ment. The  supposed  dependence  of  the  sound  on  the  placental  cir- 
culation has  caused  its  site  to  be  often  identified  with  that  of  the 
placenta.  It  is,  however,  most  frequently  heard  at  the  lower  part 
of  the  uterus,  while  the  placenta  is  generally  attached  near  the 
fundus,  so  that  its  position  cannot  be  taken  as  any  safe  guide  in 
determining  the  situation  of  that  viscus. 

jSounds  i^roduced  hj  the  Movements  of  the  Foe.ttis. — Occasionally,  in 
practising  auscultation,  irregular  sounds  of  brief  duration  may  be 
heard,  which  are  not  susceptible  of  accurate  description,  and  which 
doubtless  depend  on  the  sudden  movements  of  the  foetus  in  the 
liquor  amnii,  or  on  the  impact  of  its  limbs  on  the  uterine  walls. 
When  heard  distinctly  they  are  characteristic  of  pregnancy  ;  and 
they  may  be  sometimes  heard  when  the  other  sounds  cannot  be  de- 
tected. They  are,  however,  so  irregular,  and  so  often  entirely  absent 
that  they  can  hardly  be  looked  upon  in  any  other  light  than  as  occa- 
sional phenomena. 

Sounds  referred  to  Decomposition  of  the  Liquor  Amnii  and  to  sepa- 
ration of  the  Placenta. — Two  other  sounds  have  been  described  as 
being  sometimes  audible,  which  may  be  mentioned  as  matters  of 
interest,  but  which  are  of  no  diagnostic  value.  One  is  a  rustling 
sound,  said  by  Stoltz  to  be  audible  in  cases  in  which  the  foetus  is 
dead,  and  which  he  refers  to  gaseous  decomposition  of  the  liquor 
amnii;  its  existence  is,  however,  extremely  problematical.  The 
other  is  a  sound  heard  after  the  birth  of  the  child,  and  referred  by 
Caillant  to  the  separation  of  the  placental .  adhesions.  He  describes 
it  as  a  series  of  rapid  short  scratching  sounds,  similar  to  those  pro- 
duced by  drawing  the  nails  across  the  seat  of  a  horse-hair  sofa.    Simp- 


150  PREGNANCY. 

son'  admits  the  existence  of  the  sound,  but  believed  that  it  is  pro- 
duced by  the  mere  physical  crushing  of  the  placenta,  and  artificially 
imitated  it  out  of  the  body  by  forcing  the  placenta  throngh  an  aper- 
ture the  size  of  the  os  uteri. 

RelaMve  Value  of  the  /Signs  and  Syniptoms  of  Pregnancy.- — It  will 
be  seen,  then,  that  although  there  are  numerous  signs  and  symptoms 
accompanying  pregnancy,  many  of  them  are  unreliable  by  themselves, 
and  apt  to  mislead.  Those  which  may  be  confidently  depended  on 
are  the  pulsations  of  the  foetal  heart,  which,  however,  fail  us  incases 
of  dead  children  ;  the  foetal  movements  when  distinctly  made  out ; 
ballotternent ;  the  intermittent  contractions  of  the  uterus  ;  and  to  these 
we  may  safely  add  the  presence  of  milk  in  the  breasts,  provided  we 
have  to  do  with  a  first  pregnancy. 

The  remainder  are  of  importance  in  leadingns  to  suspect  pregnancy, 
and  in  corroborating  and  strengthening  other  symptoms,  but  they  do 
not,  of  themselves,  justify  a  positive  diagnosis. 


CHAPTEE    V, 


the  diffeeential  diagnosis  of  peegnancy.  spukious  preg- 
najstcy.  the  duration  of  pregnancy,  signs  of  recent 
pregnancy. 

Importance  of  the  Subject. — The  differential  diagnosis  of  pregnancy 
has  of  late  years  assumed  much  importance  on  account  of  the  advance 
of  abdominal  surgery.  The  cases  are  so  numerous  in  which  even 
the  most  experienced  practitioners  have  fallen  into  error,  and  in 
which  the  abdomen  has  been  laid  open  in  ignoi-ance  of  the  fact  that 
pregnancy  existed,  that  the  subject  becomes  one  of  the  greatest  con- 
sequence. Fortunately  it  is  less  so  from  an  obstetrical  than  from  a 
gyntecological  point  of  view,  inasmuch  as  the  converse  error,  of  mis- 
taking some  other  condition  for  pregnancy,  is  of  far  less  consequence, 
as  it  is  one  which  time  will  always  rectify.  But  even  in  this  way 
carelessness  vaarj  lead  to  very  serious  injury  to  the  character,  if  not  to 
the  health  of  the  patient ;  and  it  will  be  well  to  refer  briefly  to  some 
of  the  conditions  most  liable  to  be  mistaken  for  pregnancy,  and  to 
the  mode  of  distinguishing  them. 

Adipose  enlargement  of  the  abdomen  may  obscure  the  diagnosis  by 
preventing  the  detection  of  the  uterus  ;  and  if,  as  is  not  uncommon  in 
women  of  great  obesity,  it  is  associated  with  irregular  menstruation, 
the  increased  size  of  the  abdomen  might  be  supposed  to  depend  on 
pregnancy.    The  absence  of  corroborative  signs,  such  as  auscultatory 

•  Selected  Obstet.  Works,  p.  151. 


DIFFERENTIAL    DIAGNOSIS    OF    PREGNANCY.  151 

phenomena,  mammary  clianges,  and  tlie  hardness  of  the  cervix  as  felt 
per  vagi  nam,  make  it  easy  to  avoid  this  error. 

[We  are  sometimes  consulted  in  cases  of  women  in  whom  fatness 
of  body  has  commenced,  by  the  formation  of  an  adipose  cake^  which 
covers  the  centre  of  the  abdomen,  and  gives  the  infra- umbilical  por- 
tion a  protruding  roundness  veiy  much  like  that  observed  in  preg- 
nancy. In  one  case  that  my  attention  was  called  to  in  a  young  mar- 
ried woman,  I  found  the  rest  of  the  body  but  very  slightly  covered 
with  fat,  although  in  time  the  deposit  became  general,  her  weight 
then  increasing  from  120,  to  160  pounds.  Such  subjects  cither  sus- 
pect themselves  pregnant,  or  affected  with  a  tumor,  according  to  cir- 
cumstances. These  discoid  deposits  are  thick  in  the  centre,  and  thin 
toward  the  ilia,  being  in  some  instances  several  inches  thick  at  a 
point  midway  between  the  umbilicus  and  pubes. — Ed.] 

Distension  of  the  uterus  by  retained  menstrual  fluid^  or  watery 
secretion,  is  an  occurrence  of  rarity  that  could  seldom  give  rise  to 
error.  Still  it  occasionally  happens  that  the  uterus  becomes  enlarged 
in  this  way,  sometimes  reaching  even  to  the  level  of  the  umbilicus, 
and  that  the  physical  character  of  the  tumor  is  not  unlike  that  of  the 
gravid  uterus.  The  best  safeguard  against  mistakes  will  be  the 
previous  history  of  the  case,  which  will  always  be  different  from  that 
of  ordinar}^  pregnancy.  Eetention  of  the  menses  almost  always 
occurs  from  some  physical  obstruction  to  the  exit  of  the  fluid,  such 
as  imperforate  hymen;  or  if  it  occur  in  women  who  have  already 
menstruated,  we  may  usually  trace  a  history  of  some  cause,  such  as 
inflammation  following  an  antecedent  labor,  which  has  produced 
occlusion  of  some  part  of  the  genital  tract.  The  existence  of  a  pelvic 
tumor  in  a  girl  who  has  never  menstruated  will  of  itself  give  rise  to 
suspicion,  as  pregnancy  under  such  circumstances  is  of  extreme 
rarity.  It  will  also  be  found  that  general  symptoms  have  existed 
for  a  period  of  time  considerably  longer  than  the  supposed  duration 
of  pregnancy,  as  judged  of  by  the  size  of  the  tumor.  The  most 
characteristic  of  them  are  periodic  attacks  of  pain  due  to  the  addition, 
at  each  monthly  period,  to  the  quantity  of  retained  menstrual  fluid. 
Whenever,  from  any  of  these  reasons,  suspicion  of  the  true  character 
of  the  case  has  arisen,  a  careful  vaginal  examination  will  generally 
clear  it  up.  In  most  cases  the  obstruction  will  be  in  the  vagina,  and 
is  at  once  detected,  the  vaginal  canal  above  it,  as  felt  per  rectum, 
being  greatly  distended  by  fluid  ;  and  we  may  also  find  the  bulging 
and  imperforate  hymen  protruding  through  the  vulva.  The  absence 
of  mammary  changes,  and  of  ballottement,  will  materially  aid  us  in 
forming  a  diagnosis. 

Congestive  Hypertrophy  of  the  Uterus. — The  engorged  and  enlarged 
uterus,  frequently  met  with  in  women  suffering  from  uterine  disease, 
might  readily  be  mistaken  for  an  early  pregnancy,  if  it  happened  to 
be  associated  with  amenorrhoea.  A  little  time  would,  of  course,  soon 
clear  up  the  point,  by  showing  that  progressive  increase  in  size,  as 
in  pregnancy,  does  not  take  place.  This  mistake  could  only  be  made 
at  an  early  stage  of  pregnancy,  when  a  positive  diagnosis  is  never 


152  PREGNANCY. 

possible.  The  accompaiiying  symptoms — pain,  inability  to  walk,  and 
tenderness  of  the  uterus  on  pressure — ^would  further  prevent  such  an 
error. 

Ascitic  Distension  of  the  Abdomen. — Ascites,  pei'  se,  could  hardly  be 
mistaken  for  pregnane}'' ;  for  the  uniform  distension  and  evident 
fluctuation,  the  absence  of  any  definite  tumor,  the  site  of  resonance 
on  percussion  changing  in  accordance  with  alteration  of  the  position 
of  the  woman,  and  the  unchanged  cervix  and  uterus,  should  be  suffi- 
cient to  clear  up  any  doubt.  Pregnancy  may,  however,  exist  with 
ascites,  and  this  combination  may  be  difficult  to  detect,  and  might 
readily  be  mistaken  for  ovarian  disease,  associated  with  ascites.  The 
existence  of  mammary  changes,  the  presence  of  the  softened  cervix, 
ballottement,  and  auscultation — provided  the  sounds  were  not  masked 
by  the  surrounding  fluid — -would  afford  the  best  means  of  diagnosing 
such  a  case. 

Uterine  and  Ovarian  Ttimors. — One  of  the  most  frequent  sources 
of  difficulty  is  the  differential  diagnosis  of  large  abdominal  tumors, 
either  fibroid  or  ovarian,  or  of  some  enlargements  due  to  malignant 
disease  of  the  peritoneum  or  abdominal  viscera.  The  most  expe- 
rienced have  been  occasionally  deceived  under  such  circumstances. 
As  a  rule,  the  presence  of  menstruation  will  prevent  error,  as  this 
generally  continues  in  ovarian  disease,  while  in  fibroids  it  is  often 
excessive.  The  character  of  the  tumor — the  fluctuation  in  ovarian 
disease,  the  hard  nodular  masses  in  fibroid — and  the  history  of  the 
case — especially  the  length  of  time  the  tumor  has  existed — will  aid 
in  diagnosis,  while  the  absence  of  cervical  softening,  and  of  ausculta- 
tory phenomena  will  further  be  of  material  value  in  forming  a  con- 
clusion. Some  of  the  most  difficult  cases  to  diagnose  are  those  in 
which  pregnancy  complicates  ovarian  or  fibroid  disease.  Then  the 
tumor  may  more  or  less  completely  obscure  the  physical  signs  of 
pregnancy.  The  usual  shape  of  the  abdomen  will  generally  be 
altered  considerably,  and  we  may  be  able  to  distinguish  the  gravid 
uterus,  separated  from  the  ovarian  tumor  by  a  distinct  sulcus,  or  with 
the  fibroid  masses  cropping  out  from  its  surface.  Our  chief  reliance 
must  then  be  placed  in  the  alteration  of  the  cervix,  and  in  the  aus- 
cultatory signs  of  pregnancy. 

Spurious  Pregnancy. — The  condition  most  likely  to  give  rise  to 
errors  is  that  very  interesting  and  peculiar  state,  known  as  spurious 
pregnancy.  In  this  most  of  the  usual  phenomena  of  pregnancy  are 
so  strangely  simulated,  that  accurate  diagnosis  is  often  far  from  easy. 
There  are  hardly  any  of  the  more  apparent  symptoms  of  pregnancy 
which  may  not  be  present  in  marked  cases  of  this  kind.  The  abdo- 
men may  become  prominent,  the  areolse  altered,  menstruation  arrested, 
and  apparent  foetal  motions  felt ;  and,  unless  suspicion  is  aroused, 
and  a  careful  physical  examination  made,  both  the  patient  and  the 
practitioner  may  easily  be  deceived. 

Cases  in  ivhicli  Spurious  Pregnancy  Occurs. — There  is  no  period  of 
the  child-bearing  life  in  which  spurious  pregnancy  may  not  be  met 
with;  but  it  is  most  likely  to  occur  in  elderly  women  about  the 


DIFFERENTIAL    DIAGNOSIS    OS    PREGNANCY,  153 

climacteric  period,  when  it  is  generally  associated  with  ovarian  irrita- 
tion connected  with  the  change  of  life ;  or  in  younger  women,  who 
are  either  very  desirous  of  finding  themselves  pregnant,  or  who,  being 
unmarried,  have  subjected  themselves  to  the  chance  of  being  so.  In 
all  cases  the  mental  faculties  have  much  to  do  with  its  production, 
and  there  is  generally  either  very  marked  hysteria,  or  even  a  condi- 
tion closely  allied  to  insanity.  Spurious  pregnancy  is  by  no  means 
confined  to  the  human  race.  It  is  well  known  to  occur  in  many  of 
the  lower  animals.  Harvey  related  instances  in  bitches,  either  after 
unsuccessful  intercourse,  or  in  connection  with  their  being  in  heat, 
even  when  no  intercourse  had  occurred.  In  such  cases  the  abdomen 
swelled,  and  milk  appeared  in  the  mammas.  Similar  phenomena  are 
also  occasionally  met  with  in  the  cow.  In  these  instances,  as  in  the 
human  female,  there  is  probably  some  morbid  irritation  of  the  ova- 
rian system. 

Its  Si(j7is  and  Symptoms. — The  physical  phenomena  are  often  very 
well  marked.  The  apparent  enlargement  is  sometimes  very  great, 
and  it  seems  to  be  produced  by  a  projection  forward  of  the  abdomi- 
nal contents  due  to  depression  of  the  diaphragm,  together  with 
rigidity  of  the  abdominal  muscles,  and  may  even  closely  simulate 
the  uterine  tumor  on  palpation.  After  the  climacteric  it  is  frequently 
associated,  as  Gooch  pointed  out,  with  an  undue  deposit  of  fat  in  the 
abdominal  walls  and  omentum,  so  that  there  may  be  even  some  dul- 
ness  on  percussion,  instead  of  resonance  of  the  intestines.  The  foetal 
movements  are  curiously  and  exactly  simulated,  either  by  involun- 
tary contractions  of  the  abdominal  walls,  or  by  the  movement  of 
flatus  in  the  intestines.  The  patient  also  generally  fancies  that  she 
suffers  from  the  usual  sympathetic  disorders  of  pregnancy,  and  thus 
her  account  of  her  symptoms  will  still  further  tend  to  mislead. 

Sometimes  followed  hy  Spurious  Labor. — Not  only  may  the  supposed 
pregnancy  continue,  but,  at  what  would  be  the  natural  term  of  de- 
livery, all  the  phenomena  of  labor  maj^  supervene.  Many  authentic 
cases  are  on  record  in  which  regular  pains  came  on,  and  continued 
to  increase  in  force  and  frequency  until  the  actual  condition  was 
diagnosed.  Such  mistakes,  however,  are  only  likely  to  happen  when 
the  statements  of  the  patient  have  been  received  without  further 
inquiry.  When  once  an  accurate  examination  has  been  made,  error 
is  no  longer  possible. 

Methods  of  Diagnosis. — We  shall  generally  find  that  some  of  the 
phenomena  of  pregnancy  are  absent.  Possibly  menstruation,  more 
or  less  irregular,  may  have  continued.  Examination  per  vaginam 
will  at  once  clear  up  the  case,  by  showing  that  the  uterus  is  not 
enlarged,  and  that  the  cervix  is  unaltered.  It  may  then  be  very- 
difficult  to  convince  the  patient  or  her  friends  that  her  symptoms 
have  misled  her,  and  for  this  purpose  the  inhalation  of  chloroform  is 
of  great  value.  As  consciousness  is  abolished,  the  semi- voluntary 
projection  of  the  abdominal  muscles  is  prevented,  the  large  apparent 
tumor  vanishes,  and  the  bystanders  can  be  readily  convinced  that 
none  exists.     As  the  patient  recovers  the  tumor  again  appears. 


154  PREGNANCY. 

Duration  of  Pregnancy. — The  duration  of  pregnancy  in  the  human 
female  has  always  formed  a  fruitful  theme  for  discussion  amongst 
obstetricians.  The  reasons  which  render  the  point  difficult  of  deci- 
sion are  obvious.  As  the  large  majority  of  cases  occur  in  married 
women,  in  whom  intercourse  occurs  frequently,  there  is  no  means  of 
knowing  the  precise  period  at  which  conception  took  place.  The 
only  datum  which  exists  for  the  calculation  of  the  probable  date  of 
delivery  is  the  cessation  of  menstruation.  It  is  quite  possible,  how- 
ever, and  indeed  probable,  that  conception  occurred,  in  a  considerable 
number  of  instances,  not  immediately  after  the  last  period,  but  im- 
mediately before  the  proper  epoch  for  the  occurrence  of  the  next. 
Hence,  as  the  interval  between  the  end  of  one  menstruation  and  the 
commencement  of  the  next  averages  25  days,  an  error  to  that  extent 
is  always  possible.  Another  source  of  fallacy  is  the  fact,  which  has 
generally  been  overlooked,  that  even  a  single  coitus  does  not  fix  the 
date  of  conception,  but  only  that  of  insemination.  It  is  well  known 
that  in  many  of  the  lower  animals  the  fertilization  of  the  ovule  does 
not  take  place  until  several  days  after  copulation,  the  spermatozoa 
remaining  in  the  interval  in  a  state  of  active  vitality  within  the 
genital  tract.  It  has  been  shown  by  Marion  Sims  that  living  sper- 
matozoa exist  in  the  cervical  canal  in  the  human  female  some  clays 
after  intercourse.  It  is  very  probable,  therefore,  that  in  the  human 
female,  as  in  the  lower  animals,  a  considerable,  but  unknown  interval, 
occurs  between  insemination  and  actual  impregnation,  which  may 
render  calculations  as  to  the  precise  duration  of  pregnancy  altogether 
unreliable. 

Average  Time  hetiueen  Cessation  of  Menstruation  and  Delivery. — A 
large  mass  of  statistical  observations  exist,,  respecting  the  average 
duration  of  gestation,  which  have  been  drawn  up  and  collated  from 
numerous  sources.  It  would  serve  no  practical  purpose  to  reprint 
the  voluminous  tables  on  this  subject  that  are  contained  in  menstrual 
works.  They  are  based  on  two  principal  methods  of  calculation. 
First,  we  have  the  length  of  time  between  the  cessation  of  menstru- 
tion  and  delivery.  This  is  found  to  vary  very  considerably,  but  the 
largest  percentage  of  deliveries  occurs  between  the  274th  and  280th 
day  after  the  cessation  of  menstruation,  the  average  day  being  the 
27'8th  ;  but,  in  individual  instances,  very  considerable  variations  both 
above  and  below  these  limits  are  found  to  exist.  Next  we  have  a 
series  of  cases,  from  various  sources,  in  which  only  one  coitus  was 
believed  to  have  taken  place.  These  are  naturally  always  open  to 
some  doubt,  but,  on  the  whole,  they  may  be  taken  as  affording  tole- 
rably fair  grounds  for  calculation.  Here,  as  in  the  other  mode  of 
calculation,  there  are  marked  variations,  the  average  length  of  time, 
as  estimated  from  a  considerable  collection  of  cases,  being  275  days 
after  the  single  intercourse.  It  may,  therefore,  be  taken  as  certain 
that  there  is  no  definite  time  which  we  can  calculate  on  as  being  the 
proper  duration  of  pregnancy,  and,  consequently,  no  method  of  esti- 
mating the  probable  date  of  delivery  on  which  we  can  absolutely 
rely. 


DIFFERENTIAL    DIAGNOSIS    OF    PREGNANCY.  155 

Methods  of  Predicting  the  prohahle  Date. — The  prediction  of  the 
time  at  which  the  confinement  may  be  expected  is,  however,  a  point 
©f  considerable  practical  importance,  and  one  on  which  the  medical 
attendant  is  always  consulted.  Various  methods  of  making  the 
calculation  have  been  recommended.  It  has  been  customary  in  this 
country,  according  to  the  recommendation  of  Montgomery,  to  fix 
upon  ten  lunar  months,  or  280  days,  as  the  probable  period  of  gesta- 
tion, and,  as  conception  is  supposed  to  occur  shortly  after  the  cessa- 
tion of  menstruation,  to  add  this  number  of  days  to  any  day  within 
the  first  week  after  the  last  menstrual  period  as  the  most  probable 
period  of  delivery.  As,  however,  278  days  is  found  to  be  the  average 
duration  of  gestation  after  the  cessation  of  menstruation,  and  as  this 
method  makes  the  calculation  vary  from  281  to  287  days,  it  is  evi- 
dently liable  to  fix  too  late  a  date.  Naegele's  method  was  to  count 
7  days  from  the  first  appearance  of  the  last  menstrual  period,  and 
then  reckon  backwards  three  months  as  the  probable  date.  Thus, 
if  a  patient  last  commenced  to  menstruate  on  August  10,  counting  in 
this  way  from  August  17  would  give  May  17  as  the  probable  date  of 
the  delivery. 

Matthews  Duncan  has  paid  more  attention  than  any  one  else  to  the 
prediction  of  the  date  of  delivery.  His  method  of  calculating  is 
based  on  the  fact  of  278  days  being  the  average  time  between  the 
cessation  of  menstruation  and  parturition  ;  and  he  claims  to  have  had 
a  greater  average  of  success  in  his  predictions  than  on  any  other  plan. 
His  rule  is  as  follows  : — "  Find  the  day  on  which  the  female  ceased 
to  menstruate,  or  the  first  day  of  being  what  she  calls  'well.'  Take. 
that  day  nine  months  forward  as  275,  unless  February  is  included, 
in  which  case  it  is  taken  as  273  days.  To  this  add  three  days  in  the 
former  case,  or  five  if  February  is  in  the  count,  to  make  up  the  278. 
This  278th  day  should  then  be  fixed  on  as  the  middle  of  the  week, 
or,  to  make  the  prediction  the  more  accurate,  of  the  fortnight  in 
which  the  confinement  is  likely  to  occur,  by  which  means  allowance 
is  made  for  the  average  variation  of  either  excess  or  deficiency." 

Various  periodoscopes  and  tables  for  facilitating  the  calculation 
have  been  made.  The  periodoscope  of  Dr.  Tyler  Smith  (sold  by 
Messrs,  John  Smith,  52  Long  Acre)  is  very  useful  for  reference  in 
the  consulting  room,  giving  at  a  glance  a  variety  of  information, 
such  as  the  probable  period  of  quickening,  the  dates  for  the  induc- 
tion of  premature  labor,  etc.  The  following  table,  prepared  by  Dr. 
Protheroe  Smith,  is  also  easily  read,  and  is  very  serviceable : — 


156 


PREGNANCY. 


Table  for  Calculating  the  Period  of  Utero-gestation.' 


nine  Calendar  Months. 

Ten  I 

unar 

Months. 

From 

To 

Days. 

To 

Days. 

January 

September  30 

273 

October 

7 

280 

February 

October       31 

273 

November 

7 

280 

March 

November  30 

275 

December 

5 

280 

April 

December    31 

275 

January 

5 

280 

May 

January      31 

276 

February 

4 

280 

June 

February    28 

273 

March 

7 

280 

July 

March          31 

274 

April 

6 

280 

August 

April            30 

273 

May 

7 

280 

September 

May              31 

273 

June 

7 

280 

October 

June            30 

273 

July 

7 

280 

November 

July             31 

273 

August 

7 

280 

December 

August        31 

274 

September 

6 

280 

Quichening  a  Fallacious  Guide  in  estimating  Date  of  Delivery. — 
The  date  at  whicli  the  quickening  has  been  perceived  is  relied  on  by 
many  practitioners,  and  still  more  by  patients,  in  calculating  the 
probable  date  of  delivery,  as  it  is  generally  supposed  to  occur  at  the 
middle  of  pregnancy.  The  great  variations,  however,  in  the  time  at 
which  this  phenomena  is  first  perceived,  and  the  difficulty  which  is 
so  often  experienced  of  ascertaining  its  presence  with  any  certainty, 
render  it  a  very  fallacious  guide,  The  only  times  at  which  the  per- 
ception of  quickening  is  likely  to  prove  of  any  real  value  are  when 
impregnation  has  occurred  during  lactation  (when  menstruation  is 
normally  absent),  or  when  menstruation  is  so  uncertain  and  irregular 
that  the  date  of  its  last  appearance  cannot  be  ascertained.  As  quick- 
ening is  most  commonly  felt  during  the  fourth  month,  more  frequently 
in  its  first  than  in  its  last  fortnight,  it  may  thus  afford  the  only  guide 
we  can  obtain,  and  that  an  uncertain  one,  for  predicting  the  date  of 
delivery. 

Is  Protraction  of  Gestaiio7i  Possible? — From  a  medico-legal  point 
of  view  the  question  of  the  possible  protraction  of  pregnancy  beyond 
the  average  time,  and  of  the  limits  within  which  such  protraction 
can  be  admitted,  is  of  very  great  importance.  The  law  on  this  point 
varies  considerably  in  different  countries.  Thus  in  France  it  is  laid 
dow^n  that  legitimacy  cannot  be  contested  until  300  days  have  elapsed 
from  the  death  of  the  husband,  or  the  latest  possible  opportunity  for 
sexual  intercourse.  This  limit  is  also  adopted  by  Austria,  while  in 
Prussia  it  is  fixed  at  302  days.  In  England  and  America  no  fixed 
date  is  admitted,  but  while  280  days  is  admitted  as  the  "legitimum 
tempus  pariendi,"  each  case,  in  which  legitimacy  is  questioned,  is  to 

'  The  above  obstetric  "  Ready  Reckoner"  consists  of  two  columns,  one  of  calendar, 
the  other  of  lunar  months,  and  may  be  read  as  follows  : — A  patient  has  ceased  to 
menstruate  on  July  1  :  her  confinement  may  be  expected  at  soonest  about  March  31 
{the  end  of  nine  calendar  months)  ;  or  at  latest  on  April  6  {the  end  of  ten  lunar  months). 
Another  iias  ceased  to  menstruate  on  January  20  ;  her  confinement  may  be  expected 
on  September  30,  plus  20  days  {the  end  of  nine  calendar  months)  at  soonest ;  or  on  October 
7,  plus  20  days  {the  end  of  ten  lunar  months)  at  latest. 


DIFFERENTIAL    DIAGNOSIS    OF    PREGNANCY.  157 

be  decided  on  its  own  merits.  At  the  early  part  of  tlie  century  the 
question  was  much  discussed  by  the  leading  obstetricians  in  connec- 
tion with  the  celebrated  Gardner  peerage  case,  and  a  considerable 
difference  of  opinion  existed  among  them.  Since  that  time  many 
apparently  perfectly  reliable  cases  have  been  recorded,  in  which  the 
duration  of  gestation  was  obviously  much  beyond  the  average,  and 
in  which  all  sources  of  fallacy  were  carefully  excluded. 

Reliable  Cases  of  Protraction. — Not  to  burden  these  pages  with  a 
number  of  cases,  it  may  suffice  to  refer,  as  examples  of  protraction, 
to  four  well-known  instances  recorded  by  Simpson,'  in  which  the 
pregnancy  extended  respectively  to  336,  332,  319,  and  324  days  after 
the  cessation  of  the  last  menstrual  period.  In  these,  as  in  all  cases 
of  protracted  gestation,  there  is  the  possible  source  of  error  that  im- 
pregnation may  have  occurred  just  before  the  expected  advent  of  the 
next  period.  Making  an  allowance  of  23  days  in  each  instance  for 
this,  we  even  then  have  a  number  of  days  much  above  the  average, 
viz.,  313,  309,  296,  and  301.  Numerous  instances  as  curious  may  be 
found  scattered  through  obstetric  literature.  Indeed,  the  experience 
of  most  accoucheurs  will  parallel  such  cases,  which  may  be  more 
common  than  is  generally  supposed,  inasmuch  as  they  are  only  likely 
to  attract  attention  when  the  husband  has  been  separated  from  the 
wife  beyond  the  average  and  expected  duration  of  the  pregnancy. 

Protraction  coramon  in  the  Lower  Animals. — The  evidence  in  favor 
of  the  possible  prolongation  of  gestation  is  greatly  strengthened  by 
what  is  known  to  occur  in  the  lower  animals.  In  some  of  these,  as 
in  the  cow  and  the  mare,  the  precise  period  of  insemination  is  known 
to  a  certainty,  as  only  a  single  coitus  is  permitted.  Many  tables  of 
this  kind  have  been  constructed,  and  it  has  been  shown  that  there  is 
in  them  a  very  considerable  variation.  In  some  cases  in  the  cow  it 
has  been  found  that  delivery  took  place  45  days,  and  in  the  mare  48 
days  after  the  calculated  date.  Analogy  would  go  strongly  to  show, 
that  what  is  known  to  a  certainty  to  occur  in  the  lower  animals,  may 
also  take  place  in  the  human  female.  The  fact,  indeed,  is  now  very 
generally  admitted ;  but  we  are  still  unable  to  fix,  with  any  degree 
of  precision,  on  the  extreme  limit  to  which  ])rotraction  is  possible. 
Some  practitioners  have  given  cases  in  which,  on  data  which  they 
believe  to  be  satisfactory,  pregnancy  has  been  extremely  protracted; 
thus  Meigs  and  Adler  record  instances  which  they  believed  to  have 
been  prolonged  to  over  a  year  in  one  case,  and  over  fourteen  months 
in.  the  other.  These  are,  however,  so  problematical  that  little  weight 
can  be  attached  to  them.  On  the  whole  it  would  hardly  be  safe  to 
conclude  that  pregnancy  can  go  more  than  three  or  four  weeks  be- 
yond the  average  time.  This  conclusion  is  justified  by  the  cases  we 
possess  in  which  pregnancy  followed  a  single  coitus,  the  longest  of 
which  was  295  days. 

Evidence  fro'ra  Size  of  Child. — Dr.  Duncan^  is  inclined  to  refuse 
credence  to  every  case  of  supposed  protraction  unless  the  size  and 

'  Obstet.  Memoirs,  p.  84. 

2  Fecundity  and  Fertility,  p.  348. 


158  PREGNANCY. 

weight  of  the  child  are  above  the  average,  believing  that  lengthened 
gestation  must  of  necessity  cause  increased  growth  of  the  child.  The 
point  requires  further  investigation,  and  it  cannot  be  taken  as  proved 
that  the  foetus  necessarily  must  be  large  because  it  has  been  retained 
longer  than  usual  in  utero  ;  or,  even  if  this  be  admitted,  it  may  have 
been  originally  small,  and  so,  at  the  end  of  the  protracted  gestation, 
be  little  above  the  average  weight.  There  are,  however,  many  cases 
which  certainly  prove  that  a  prolonged  pregnancy  is  at  least  often 
associated  with  an  unusually  developed  foetus.  Dr.  Duncan  himself 
cites  several,  and  a  very  interesting  one  is  mentioned  by  Leishman, 
in  which  dehvery  took"^ place  295  days  after  a  single  coitus,  the  child 
weighing  12  lbs.  3  oz. 

Ill  some  Cases  Labor  may  comm.ence  and  he  Arrested. — It  seems 
possible  that,  in  some  cases  of  protracted  pregnancy,  labor  actually 
came  on  at  the  average  time,  but,  on  account  of  faulty  positions  of 
the  uterus,  or  other  obstructing  cause,  the  pains  were  ineffective  and 
ultimately  died  away,  not  recurring  for  a  considerable  time.  Joulin 
relates  some  instances  of  this  kind.  In  one  of  them  the  labor  was 
expected  from  the  20th  to  the  25th  of  October.  He  was  summoned 
on  the  23d,  and  found  the  pains  regular  and  active,  but  ineffective ; 
after  lasting  the  whole  of  the  24:th  and  25th  they  died  away,  and 
delivery  did  not  take  place  until  November  25th,  after  theJapse  of  a 
month.  In  this  instance  the  apparent  cause  of  difficulty  was  extreme 
anterior  obliquit}^  of  the  uterus.  A  precisely  similar  case  came 
under  my  own  observation.  The  lady  ceased  to  menstruate  on 
March  16,  1870.  On  December  12th,  that  is,  on  the  273d  day,  strong 
labor  pains  came  on,  the  os  dilated  to  the  size  of  a  florin,  and  the 
membranes  became  tense  and  prominent  with  each  pain.  After  last- 
ing all  night  they  gradually  died  away,  and  did  not  recur  until  Jan- 
uary 12  th,  30-1  days  from  the  cessation  of  the  last  period.  Plere 
there  was  no  assignable  cause  of  obstruction,  and  the  labor,  when  it 
did  come  on,  was  natural  and  easy. 

The  curious  fact  that,  in  both  these  cases,  as  in  others  of  the  same 
kind  that  are  recorded,  labor  came  on  exactly  a  month  after  the  pre- 
vious ineffectual  attempt  at  its  establishment,  affords,  so  far  as  it 
goes,  an  argument  in  favor  of  the  view  maintained  by  many  that 
labor  is  apt  to  come  on  at  what  would  have  been  a  menstrnal  period. 

Si(jns  of  Recent  Delivery. — From  a  forensic  point  of  view  it  often 
becomes  of  importance  to  be  able  to  give  a  reliable  opinion  as  to  the 
fact  of  delivery  having  occurred,  and  a  few  words  may  be  here  said 
as  to  the  signs  of  recent  delivery.  Our  opinion  is  only  likely  to  be 
sought  in  cases  in  which  the  fact  of  delivery  is  denied,  and  in  which 
we  must,  therefore,  entirely  rely  on  the  results  of  a  physical  exami- 
nation. If  this  be  undertaken  within  the  first  fortnight  after  labor, 
a  positive  conclusion  can  be  readily  arrived  at. 

At  this  time  the  abdominal  walls  will  still  be  found  loose  and 
flaccid,  and  bearing  very  evident  marks  of  extreme  distension  in  the 
cracks  and  fissures  of  the  cutis  vera.  These  remain  permanent  for 
the  rest  of  the  patient's  life,  and  may  be  safely  assumed  to  be  signs 
of  an  antecedent  pregnancy,  provided  we  can  be  certain  that  no  other 


DIFFERENTIAL    DIAGNOSIS    OF    PREGNANCY.  159 

cause  of  extreme  abdominal  distension  lias  existed,  sucli  as  ascites, 
or  ovarian  tumor. 

Within  the  first  few  days  after  delivery,  the  hard  round  ball 
formed  by  the  contracted  and  empty  uterus  can  easily  be  felt  by 
abdominal  palpation,  and  more  certainly  by  combined  external  and 
internal  examination.  The  process  of  involution,  however,  by  which 
the  uterus  is  reduced  to  its  normal  size,  is  so  rapid,  that  after  the  first 
week  it  can  no  longer  be  made  out  above  the  brim  of  the  pelvis.  In 
cases  in  which  an  accurate  diagnosis  is  of  importance,  the  increased 
length  of  the  uterus  can  be  ascertained  by  the  uterine  sound,  and  its 
cavity  will  measure  more  than  the  normal  2|  inches  for  at  least  a 
month  after  delivery.  It  should  not  be  forgotten  that  the  uterine 
parietes  are  now  undergoing  fatty  degeneration,  and  that  they  are 
more  than  usually  soft  and  friable,  so  that  the  sound  should  be  used 
with  great  caution,  and  only  when  a  positive  opinion  is  essential. 
The  state  of  the  cervix  and  of  the  vagina  may  afford  useful  in- 
formation. Immediately  after  delivery  the  cervix  hangs  loose  and 
patulous  in  the  vagina,  but  it  rapidly  contracts,  and  the  internal  os 
is  generally  entirely  closed  after  the  eighth  or  tenth  day.  The  re- 
mainder of  the  cervix  is  longer  in  returning  to  its  normal  shape  and 
consistency.  It  is  generally  permanently  altered  after  delivery,  the 
external  os  remaining  fissured  and  transverse,  instead  of  circular  with 
smooth  margins,  as  in  virgins.  The  vagina  is  at  first  lax,  swollen, 
and  dilated,  but  these  signs  rapidly  disappear  and  cannot  be  satisfac- 
torily made  out  after  the  first  few  days.  The  absence  of  the  fourchette 
may  be  recognized,  and  is  a  persistent  sign. 

The  presence  of  the  lochia  affords  a  valuable  sign  of  recent  deliv- 
ery. For  the  first  few  days  they  are  sanguineous,  and  contain  numer- 
ous blood-corpuscles,  epithelial  scales,  and  the  debris  of  the  clecidua. 
After  the  fifth  day  they  generally  change  in  color,  and  become  pale 
and  greenish,  and  from  the  eighth  or  ninth  day  till  about  a  month 
after  delivery,  they  have  the  appearance  of  a  thick  opalescent  rnucus. 
They  have,  however,  a  peculiar,  heavy,  sickening  odor,  which  should 
prevent  their  being  mistaken  for  either  menstruation  or  leucorrhoeal 
discharge. 

The  appearance  of  the  breasts  will  also  aid  the  decision,  for  it  is 
impossible  for  the  patient  to  conceal  the  turgid  swollen  condition  of 
the  mammge,  with  the  darkened  areolae,  and,  above  all,  the  presence 
of  milk.  If,  on  microscopic  examination,  the  milk  is  found  to  con- 
tain colostrum  corpuscles,  the  fact  of  very  recent  delivery  is  certain. 
In  women  who  do  not  nurse  it  should  be  remembered  that  the  secre- 
tion of  milk  often  rapidly  disappears,  so  that  its  absence  cannot  be 
taken  as  a  sign  that  delivery  has  not  taken  place.  On  the  whole, 
there  should  be  no  diffi.culty  in  deciding  that  a  woman  has  been  de- 
livered, as  some  of  the  signs  are  persistent  for  the  rest  of  her  life ; 
but  it  is  not  so  easy  unless  we  see  the  case  within  the  first  eight  or 
ten  days,  to  say  how  long  it  is  since  labor  took  place. 


160  PREG^^ANCY. 


CHAPTER  YI. 

ABNORMAL  PREGNAISrCY,  INCLUDING  MULTIPLE  PREGNANCY,  SUPEE- 
FCETATION,  EXTRA-UTERINE  FCETATION,  AND  MISSED  LABOR. 

Plural  Births  an  ahnormal  variety  of  Pregnancy. — The  occurrence 
of  more  than  one  foetus  in  utero  is  far  from  uncommon,  but  there 
are  circumstances  connected  with  it  which  justify  the  conclusion  that 
plural  births  must  not  be  classified  as  natural  forms  of  pregnancy. 
The  reasons  for  this  statement  have  been  well  collected  by  Dr. 
Arthur  Mitchell,^  who  conclusively  shows  that  not  only  is  there  a 
direct  increase  of  risk  both  to  the  mother  and  her  offspring,  but  that 
many  abnormalities,  such  as  idiocy,  imbecility,  and  bodily  deformity, 
occur  with  much  greater  frequency  in  twins  than  in  single-born 
children.  He  concludes  that  "  the  whole  history  of  tAvin  births  is 
exceptional,  indicates  imperfect  development  and  feeble  organization 
in  the  product,  and  leads  us  to  regard  twinning  in  the  human  species 
as  a  departure  from  the  physiological  rule,  and  therefore  injurious 
to  all  concerned." 

Frequency  of  multiple  Births. — The  frequency  of  multiple  births 
varies  considerably  under  dii^'erent  circumstances.  Taking  the  aver- 
age of  a  large  number  of  cases  collected  by  authors  in  various 
countries,  we  find  that  twin  pregnancies  occur  about  once  in  87 
labors  ;  triplets  once  in  7679.  A  certain  number  of  quadruple  preg- 
nancies, and  some  cases  of  early  abortion  in  which  there  were  five 
foetuses,  are  recorded,  so  that  there  can  be  no  doubt  of  the  possibility 
of  such  occurrences  ;  but  they  are  so  extremely  uncommon  that  they 
may  be  looked  upon  as  rare  exceptions,  the  relative  frequency  of 
which  can  hardly  be  determined. 

Relative  frequency  in  different  Countries. — The  frequency  of  mul- 
tiple pregnancy  varies  remarkably  in  different  races  and  countries. 
The  following  table^  will  show  this  at  a  glance  : — 

1  Med.  Times  and  Gaz.,  Nov.  lSfi2. 

2  Puecli,  Des  Naissances  Multiples. 


ABNORMAL    PREGNANCY. 


161 


Eelative  Frequency  of  Multiple  Pregnancies  in  Europe. 


Countries. 

Proportion  of 

Twin  to  Single 

Births. 

Proportion  of 
Triplets. 

Proportion  of 
Qaadruplots. 

1   :  116 

1  :  94 
1  :  89 
1   :  95 
1   :  99 
1   :   64 
1  :   68.9 
1   :  81.62 
1   :  89 
1  :  50.05 
1  :  79 
1  :  102 
1  :  862 

1   :   6,720 

Austria  . 

Grand  Duchy  of  Baden 

Scotland 

France    . 

Ireland  . 

Mecklenburg-Scliwerin 

Norway  . 

Prussia  . 

Russia    . 

Saxony  . 

1   :  6,575 

1   :  8,256 
1   :  4,995 
1   :   6,436 
1   :  5,442 
1   :  7,820 
1   :  4,054 
1   :  1,000 

l':   6,464 

1   :  2,074,306 
1   :   167,296 
1  :  183,236 

1   :  394,690 

1  :  400,000 

Wurtemberg  . 

1   :  110,991 

It  will  be  seen  that  the  largest  proportion  of  multiple  births  occurs 
in  Eussia,  and  that  the  number  of  triple  births  is  greatest  where  twin 
pregnancies  are  most  frequent.  Paech  concludes  that  the  number  of 
multiple  pregnancies  is  in  direct  proportion  to  the  general  fecundity 
of  the  inhabitants. 

Dr.  Duncan  has  deduced  some  interesting  laws,  with  regard  to  the 
production  of  twins,  from  a  large  number  of  statistical  observations;^ 
especially  that  the  tendency  to  the  production  of  twins  increases  as 
the  age  of  the  woman  advances,  and  is  greater  in  each  succeeding 
pregnancy,  exception  being  made  for  the  first  pregnancy,  in  which  it 
is  greater  than  in  any  other.  Newly  married  women  appear  more 
likely  to  have  twins  the  older  they  are.  There  can  be  no  doubt  that 
there  is  often  a  strong  hereditary  tendency  in  individual  families  to 
multiple  births.  A  remarkable  instance  of  this  kind  is  recorded  by 
Mr.  Curgenven,^  in  which  a  woman  had  fonr  twin  pregnancies,  her 
mother  and  aunt  each  one,  and  her  grandmother  two.  Simpson 
mentions  a  case  of  quadruplets,  consisting  of  three  males  and  one 
female,  who  all  survived,  the  female  subsequently  giving  birth  to 
triplets.* 

Sex  of  Children. — -In  the  largest  nnmber  of  cases  of  twins  the 
children  are  of  opposite  sexes,  next  most  frequently  there  are  two 
females,  and  twin  males  are  the  most  uncommon.  Thus  out  of 
59,178  labors,  Simpson  calculates  that  twin  male  and  female  occurred 
once  in  199  labors,  twin  females  once  in  226,  and  twin  males  once  in 
258.  The  proportion  of  male  to  female  births  is  also  notably  less  in 
twin  than  in  single  pregnancies. 

Size  of  Foetuses. — Twins,  and  d,  fortiori  triplets,  are  almost  ahvays 
smaller  and  less  perfectly  developed  than  single  children.  Hence 
the  chances  of  their  survival  are  much  less,  and  Clarke  calculates 
the  mortality  amongst  twin  children  as  one  out  of  thirteen.  Of 
triplets,  indeed,  it  is  comparatively  rare  that  all  survive ;  while  in 


'  On  Fecundity,  Fertility,  and  Sterility,  p.  99. 

2  Obstet.  Trans.,  vol.  xi.  »  Obstet.  Works,  p.  830. 


162  PREGNANCY. 

quadruplets,  premature  labor  and  the  death  of  the  foetuses  are  almost 
certain.  It  is  a  common  observation  that  twins  are  often  unequally 
developed  at  birth.  Bj  some  this  difference  is  attributed  to  one  of 
them  being  of  a  different  age  to  the  other.  It  is  probable,  however, 
that  in  most  of  these  cases  the  full  development  of  one  fostus  has  been 
interfered  with  by  pressure  of  the  other.  This  is  far  from  uncom- 
monly carried  to  the  extent  of  destroying  one  of  the  twins,  which  is 
expelled  at  term,  mummified  and  flattened  between  the  living  child 
and  the  uterine  wall.  In  other  cases  when  one  foetus  dies  it  may  be 
expelled  without  terminating  the  pregnancy,  the  other  being  retained 
in  utero  and  born  at  term  ;  and  those  who  disbelieve  in  the  possi- 
bility of  superfoetation  explain  in  this  w^ay  the  cases  in  which  it  is 
believed  to  have  occurred. 

Causes.' — Multiple  pregnancies  depend  on  various  causes.  The 
most  common  is  probably  the  simultaneous,  or  nearly  simultaneous, 
maturation  and  rupture  of  two  Graafian  follicles,  the  ovules  becoming 
impregnated  at  or  about  the  same  time.  It  by  no  means  necessarily 
follows,  even  if  more  than  one  follicle  should  ruptui-e  at  once,  that 
both  ovules  should  be  impregnated.  This  is  proved  by  the  occur- 
rence of  cases  in  which  there  are  two  corpora  lutea  with  only  one 
foetus.  There  are  numerous  facts  to  prove  that  ovules  thrown  off 
Avithin  a  short  time  of  each  other,  may  become  ssparately  impreg- 
nated, as  in  cases  in  which  negro  women  have  given  birth  to  twins, 
one  of  whicli  was  pure  negro,  the  other  half-caste. 

It  may  happen,  however,  that  a  single  Graafian  follicle  contains 
more  than  one  ovule,  as  has  actually  been  observed  before  its  rup- 
ture ;  or,  as  is  not  uncommon  in  the  egg  of  the  fowl,  an  ovule  may 
contain  a  double  germ,  each  of  which  may  give  rise  to  a  separate 
foetus. 

Arrangem.ent  of  the  Foetal  3femhra7ies  and  Placentse. — The  various 
modes  in  which  twins  may  originate  explain  satisfactorily  the  varia- 
tions which  are  met  with  in  the  arrangement  of  the  foetal  membranes, 
and  in  the  form  and  connections  of  the  placentas.  In  a  large  propor- 
tion of  cases  there  are  two  distinct  bags  of  membranes,  the  septum 
between  them  being  composed  of  four  layers,  viz.j  the  chorion  and 
amnion  of  each  ovum.  The  placentge  are  also  entirely  separate. 
Here  it  is  obvious  that  each  twdn  is  developed  from  a  distinct  ovum, 
having  its  own  chorion  and  amnion.  On  arriving  in  the  uterus  it  is 
probable  that  each  ovum  becomes  fixed  independently  in  the  mucous 
membrane,  and  is  surrounded  by  its  own  decidua  reflexa.  As  growth 
advances,  the  decidua  reflexa  generally  atrophies  from  pressure,  as 
it  is  not  usual  to  find  more  than  four  layers  of  membrane  in  the 
septum  separating  the  ova.  In  other  cases  there  is  only  one  chorion, 
within  which  are  two  distinct  amnions,  the  septum  then  consisting  of 
two  layers  only.  Then  the  placentae  are  generally  in  close  apposi- 
tion, and  become  fused  into  a  single  mass  ;  the  cords,  separately 
attached  to  each  foetus,  not  infrequently  uniting  shortly  before  reach- 
ing the  placental  mass,  their  vessels  anastomosing  freely.  In  other 
more  rare  instances  both  foetuses  are  contained  in  a  common  amni- 
otic sac ;  but,  as  the  amnion  is  a  purely  foetal  membrane,  it  is  prob- 


ABNORMAL    PREGNANCY.  163 

able  that,  wlien  tins  arrangement  is  met  with,  the  originally  existing 
septum  between  the  amniotic  sacs  has  been  destroyed.  In  both 
these  latter  cases  the  twins  must  have  been  developed  from  a  single 
ovule  containing  a  double  germ,  and  Schroeder  states  that  they  are 
then  always  of  the  same  sex.  Dr.  Brunton^  has  started  a  precisely 
opposite  theory,  and  has  tried  to  prove  that  twins  of  the  same  sex 
are  contained  in  separate  bags  of  membrane,  while  twins  of  opposite 
sexes  have  a  common  sac.  He  says  that  out  of  twenty-live  cases 
coming  under  his  observation,  in  iifteen  the  children  contained  in 
different  sacs  were  of  the  same  sex,  but  in  the  remaining  ten,  in 
which  there  was  only  one  sac,  they  were  of  opposite  sexes.  It  is 
difficult  to  believe  that  there  is  not  an  error  in  these  observations, 
^ince  twins  contained  in  a  single  amniotic  sac  do  not  occur  nearly 
as  often  as  ten  times  out  of  twenty-five  cases,  and  no  distinction  is 
made  between  a  common  chorion  with  two  amnions  and  a  single 
chorion  and  amnion.  The  facts  of  double  monstrosity  also  disprove 
this  view,  since  conjoined  twins  must  of  necessity  arise  from  a  single 
ovule  with  a  double  germ,  and  there  is  no  instance  on  record  in  which 
they  were  of  opposite  sexes. 

Membranes  and  Placentse  in  Triplets. — In  triplets  the  membranes 
and  placentse  may  be  all  sepai'ate,  or  as  is  commonly  the  case  there 
is  one  complete  bag  of  membranes,  and  a  second  having  a  common 
chorion,  with  a  double  amnion.  It  is  probable,  therefore,  that  trip- 
lets are  generally  developed  from  two  ovules,  one  of  which  contained 
a  double  germ. 

Diagnos's  of  Multiph  Pregnancy. — It  is  comparatively  seldom  that 
twin  pregnancy  can  be  diagnosed  before  the  birth  of  the  first  child, 
and  even  when  suspicion  has  arisen,  its  indications  are  very  defective. 
There  is  generally  an  unusual  size  and  an  irregularit}^  of  shape  of 
the  uterus,  sometimes  even  a  distinct  depression  or  sulcus  between 
the  two  foetuses.  When  such  a  sulcus  exists  it  may  be  possible  to 
make  out  parts  of  each  foetus  by  palpation  on  either  side  of  the 
uterus.  The  only  sign,  however,  on  which  the  least  reliance  can  be 
placed  is  the  detection  of  two  foetal  hearts.  If  two  distinct  pulsa- 
tions are  heard  at  different  parts  of  the  uterus ;  if,  on  carrying  the 
stethoscope  from  one  point  to  another,  there  is  an  interspace  where 
pulsations  are  no  longer  audible,  or  when  they  become  feeble,  and 
again  increase  in  clearness  as  the  second  point  is  reached  ;  and,  above 
all,  if  we  are  able  to  make  out  a  difference  in  frequency  between 
them,  the  diagnosis  is  tolerably  safe.  It  must  be  remembered,  how- 
ever, that  the  sounds  of  a  single  heart  may  be  heard  over  a  larger 
space  than  usual,  and  hence  a  possible  source  of  error.  Twin  preg- 
nancy, moreover,  may  readily  exist  without  the  most  careful  auscul- 
tation enabling  us  to  detect  a  double  pulsation,  especially  if  one  child 
lie  in  the  dorso-posterior  position,  when  the  body  of  the  other  may 
prevent  the  transmission  of  its  heart's  beat.  The  so-called  placental 
souffle  is  generally  too  diffuse  and  irregular  to  be  of  any  use  in 
diagnosis,  even  when  it  is  distinctly  heard  at  separate  parts  of  the 
uterus. 

'  Obst.  Trans.,  vol.  x. 


16-1  PREGNANCY. 

Superfoetation  and  Siiperfecundation. — Closel}^  connected  with  the 
subject  of  multiple  pregnancies  are  the  conditions  known  as  super- 
fecundation  and  su'perfoitation^  regarding  Avhich  there  has  been  much 
controversy  and  difi'erence  of  opinion. 

By  the  former  is  meant  the  fecundation,  at  or  near  the  same  period 
of  time,  of  two  separate  ovules  before  the  decidua  lining  the  uterus 
has  been  formed,  which  by  many  is  supposed  to  form  an  insuperable 
obstacle  to  subsequent  impregnation.  The  possibility  of  this  occur- 
rence has  been  incontestably  proved  by  the  class  of  cases  already 
referred  to,  in  which  the  same  woman  has  given  birth  to  twins  bear- 
ing evident  traces  of  being  the  offspring  of  fathers  of  different  races. 

By  superfoetation  is  meant  the  impregnation  of  a  second  ovule, 
when  the  uterus  already  contains  an  ovum  which  has  arrived  at  a 
considerable  degree  of  development.  The  cases  which  are  supposed 
to  prove  the  possibility  of  this  occurrence  are  very  numerous.  They 
are  those  in  which  a  woman  is  delivered  simultaneously  of  foetuses 
of  very  different  ages,  one  bearing  all  the  marks  of  having  arrived 
at  term,  the  other  of  prematurity ;  or  of  those  in  which  a  woman  is 
delivered  of  an  apparently  mature  child,  and,  after  the  lapse  of  a  few 
months,  of  another  equally  mature.  The  possibility  of  superfoetation 
is  strongly  denied  by  many  practitioners  of  eminence,  and  explana- 
tions are  given,  wiiich  doubtless  seem  to  account  satisfactorily  for  a 
large  proportion  of  the  supposed  examples.  In  the  former  class  of 
cases  it  is  supposed,  with  much  probability,  that  there  is  an  ordinary 
twin  pregnancv,  the  development  of  one  foetus  being  retarded  by  the 
presence  in  utero  of  another.  That  this  is  not  an  uncommon  occur- 
rence is  certain,  and  the  fact  has  already  been  alluded  to  in  treating 
of  twin  pregnancy.  In  cases  of  the  latter  kind  it  is  possible  that 
some  of  them  may  be  due  to  separate  impregnation  in  a  bilobed 
uterus,  the  contents  of  one  division  being  thrown  off  a  considerable 
time  before  those  of  the  other.  Numerous  authentic  examples  of 
this  occurrence  are  recorded,  but  by  far  the  most  remarkable  is  that 
related  by  Dr.  Eoss,  of  Brighton,  which  has  been  already  referred  to 
(p.  58.)  In  this  case  the  patient  had  previously  given  birth  to  many 
children  without  any  suspicion  of  her  abnormal  formation  having 
arisen,  and,  had  it  not  been  detected  by  Dr.  Eoss,  the  case  might 
fairly  enough  have  been  claimed  as  an  indubitable  example  of  super- 
foetation. 

Making  every  allowance  for  these  explanations,  there  remain  a 
considerable  number  of  cases  which  it  is  very  difficult  to  account  for, 
except  on  the  supposition  that  the  second  child  has  been  conceived  a 
considerable  time  after  the  first.  Those  interested  in  the  subject 
will  find  a  large  number  of  examples  collected  in  a  valuable  paper 
by  Dr.  Bonnar,  of  Cupar.^  lie  has  adopted  the  ingeniou.i  plan  of 
consulting  the  records  of  the  British  peerage,  where  the  exact  elate 
of  the  birth  of  successive  children  of  peers  is  given,  without,  of 
course,  any  reasonable  possibility  of  error,  and  he  has  collected 
numerous  examples  of  births  rapidly  succeeding  each  other,  which 

1  Edin.  Med.  Journ.,  1864-65. 


ABNORMAL    PREGNANCY.  165 

are  apparently  inexplicable  on  any  other  theory.  In  one  case  he 
cites,  a  child  was  born  September  12,  1849,  and  the  mother  gave 
birth  to  another  on  January  24,  1850,  after  an  interval  of  only  127 
days.  Subtracting  from  that  14  days,  which  Dr.  Bonnar  assumes  to 
be  the  earliest  possible  period  at  which  a  fresh  impregnation  can 
occur  after  delivery,  we  reduce  the  gestation  to  118  days,  that  is,  to 
less  than  four  calendar  months.  As  both  these  children  survived, 
the  second  child  could  not  possibly  have  been  the  result  of  a  fresh 
impregnation  after  the  birth  of  the  tirst ;  nor  could  the  first  child 
have  been  a  twin  prematurely  delivered,  for  if  so  it  must  have  only 
reached  rather  more  than  the  fifth  month,  at  which  time  its  survival 
would  have  been  impossible. 

Besides  the  numerous  examples  of  cases  of  this  kind  recorded  in 
most  obstetric  works,  there  are  one  or  two  of  miscarriage  in  the 
early  months,  in  which,  in  addition  to  a  foetus  of  four  or  five  months' 
growth,  a  perfectly  fresh  ovum  of  not  more  than  a  month's  develop- 
ment was  thrown  off.  One  such  case  was  shown  at  the  Obstetrical 
Society  in  1862,  which  was  reported  on  by  Drs.  Harley  and  Tanner, 
who  stated  that  in  their  opinion  it  was  an  example  of  superfoetation. 
A  still  more  conclusive  case  is  recorded  by  Tyler  Smith.'  "  A  young 
married  woman,  pregnant  for  the  first  time,  miscarried  at  the  end  of 
the  fifth  month,  and  some  hours  afterwards  a  small  clot  was  dis- 
charged, inclosing  a  perfectly  healthy  ovum  of  about  one  month. 
There  were  no  signs  of  a  double  uterus  in  this  case.  The  patient  had 
menstruated  regularly  during  the  time  she  had  been  pregnant."  This 
case  is  of  special  interest  from  the  fact  of  the  patient  having  men- 
struated during  pregnancy — a  circumstance  only  explicable  on  the 
same  anatomical  grounds  which  render  superfoetation  possible.  So 
far  as  I  know,  it  is  the  only  instance  in  which  the  coincidence  of 
superfostation  and  menstruation  during  early  pregnancy  has  been 
observed. 

Objections. — The  objections  to  the  possibility  of  superfoetation  are 
based  on  the  assumptions  that  the  deoidua  so  completely  fills  up  the 
uterine  cavity  that  the  passage  of  the  spermatozoa  is  impossible; 
that  their  passage  is  prevented  by  the  mucous  plug  whicli  blocks  up 
the  cervix ;  and  that  when  impregnation  has  taken  place  ovulation 
is  suspended.  It  is,  however,  certain  that  none  of  these  are  insupera- 
ble obstacles  to  a  second  impregnation.  Tlie  first  was  originally 
based  on  the  older  and  erroneous  view  which  considered  the  decidua 
to  be  an  exudation  lining  the  entire  uterine  cavity,  and  sealing  up 
the  mouths  of  the  Fallopian  tubes  and  the  aperture  of  the  internal  os 
uteri.  The  decidua  reflexa,  however,  does  not  come  into  apposition 
with  the  decidua  vera  until  about  the  eighth  week  of  pregnancy,  and, 
therefore,  until  that  time  there  is  a  free  space  between  the  two  mem- 
branes  through  which  the  spermatozoa  might  pass  to  the  open 
m.ouths  of  the  Fallopian  tube,  and  in  which  a  newly  impregnated 
ovule  might  graft  itself.  A  reference  to  the  accompanying  figure  of 
a  pregnancy  in  the  third    month,  copied  from    Coste's  work,  will 

'  Manual  of  Obstetrics,  p.  112. 


166 


PREGNANCY. 


readily  show  that,  as  far  as  the  decidua  is  concerned,  there  is  no 
mechanical  obstacle  to  the  descent  and  lodgment  of  another  impreg- 
nated ovule  (Fig.  76).  Then,  as  regards  the  plug  of  mucus,  it  is 
pretty  certain  that  this  is  in  no  way  difi'ereut  from  the  mucus  filling 


Fig.  76. 


Illustrating  the  Cavity  betweRu  the  Decidua  Vera  ani  the  Decidua  Reflexa  during  the  early- 
mouths  of  Pi-egnancy.     (After  Coste.) 

the  cervix  in  the  non-pregnant  state,  which  offers  no  obstacle  at  all 
to  the  passage  of  the  spermatozoa.  Lastly,  respecting  the  cessation 
of  ovulation  during  pregnancy,  this,  no  doubt,  is  the  rule,  and  proba- 
bly satisfactorily  explains  the  rarity  of  superfoetation.  There  are, 
however,  a  sufficient  number  of  authenticated  cases  of  menstruation 
during  pregnancy  to  prove  that  ovulation  is  not  always  absolutely 
in  abeyance;  and,  as  long  as  it  occurs,  there  is  unquestionably  no 
positive  mechanical  obstruction,  at  least  in  the  early  months  of  preg- 
nancy, in  the  way  of  the  impregnation  and  lodgment  of  the  ovules 
that  are  thrown  off.  The  reasonable  conclusion,  therefore,  seems  to 
be  that,  although  a  large  majority  of  the  supposed  cases  are  explica- 
ble in  other  ways,  it  cannot  be  admitted  that  superfcetation  is  either 
physiologically  or  mechanically  impossible. 

Extra-uterine  Pregnancy . — The  most  important  of  the  abnormal 
varieties  of  pregnancy,  if  we  consider  the  serious  and  verj^  generally 
fatal  results  attending  it,  is  the  so-called  extra-7iterine  foetation^  which 
consists  in  the  arrest  and  development  of  the  ovum  outside  the 
cavity  of  the  uterus.  Of  late  years  this  subject  has  received  much 
well-merited  attention,  which,  it  is  to  be  hoped,  may  lead  to  the 
establishment  of  some  definite  rules  for  the  management  of  this 
most  anxious  and  dangerous  class  of  cases 


ABNORMAL    PREGNANCY.  167 

Site  of  Extra-uterine  Prefjnancy . — The  ovum  may  be  arrested  and 
developed  in  various  situations  on  its  way  to  the  uterus,  most  com- 
monly in  some  part  of  the  Fallopian  tube,  or  it  may  be  in  the  cavity 
of  the  abdomen,  or  even  quite  beyond  it,  as  in  a  few  rare  cases  in 
which  the  ovum  has  found  its  way  into  a,  hernial  sac. 

Classification. — Extra-uterine  gestation  may  be  subdivided  into  the 
following  classes:  1st,  and  most  common  of  all,  tuhal  gestation  and 
as  varieties  of  this,  although  by  some  made  into  distinct  classes  («) 
interstitial  and  (/;)  tubo-ovarian  gestation.  In  the  former  of  these 
subdivisions  the  ovum  is  arrested  in  the  part  of  the  Fallopian  tube 
that  is  situated  in  the  substance  of  the  uterine  j)arietes;  in  the  latter, 
at  or  near  the  fimbriated  extremity  of  the  tube — so  that  part  of  its 
cyst  is  formed  by  the  tube  and  part  by  the  ovary,  2d,  Ahdorainal 
gestation,  in  which  an  ovum,  instead  of  finding  its  way  into  the  tube, 
falls  into  the  peritoneal  cavity  and  there  becomes  attached  and  de- 
veloped ;  or  the  so-called  secondary  abdominal  gestation,  in  which  an 
extra-uterine  pregnancy,  originally  tubal,  becomes  ventral,  through 
rupture  of  its  cysts  and  escape  of  its  contents  into  the  abdominal 
cavity.  3d.  Ovarian  gestation,  the  existence  of  which  is  denied  by 
many  writers  of  eminence,  such  as  Velpeau  and  Arthur  Farre,  while 
it  is  maintained  by  others  of  equal  celebrity,  such  as  Kiwisch,  Coste, 
and  Hecker.  It  must  be  admitted  that  it  is  extremely  difiicult  to 
understand  how  an  ovarian  pregnane}^,  in  the  strict  sense  of  the  word, 
can  occur,  for  it  implies  that  the  ovule  has  become  impregnated  before 
the  laceration  of  the  Graafian  follicle,  through  the  coats  of  which  the 
spermatozoa  must  have  passed.  Coste,  indeed,  believes  that  this 
frequently  occurs ;  but,  while  spermatozoa  have  been  detected  on  the 
surface  of  the  ovary,  their  penetration  into  the  Graafian  follicle  has 
never  been  demonstrated.  Farre  has  also  clearly  shown  that  in  manv 
cases  of  supposed  ovarian  pregnancy  the  surrounding  structures  Avere 
so  altered  that  it  was  impossible  to  trace  their  exact  origin,  and  to 
say,  to  a  certainty,  that  the  foetus  was  really  within  the  substance  of 
the  ovary.  Kiwisch  gives  a  reasonable  explanation  of  these  cases 
by  supposing  that  sometimes  the  Graafian  follicle  may  rupture,  but 
that  the  ovule  may  remain  within  it  without  being  discharged. 
Through  the  rent  i:i  the  walls  of  the  follicle  the  spermatozoa  mav 
reach  and  impregnate  the  ovule,  which  may  develop  in  the  situation 
in  which  it  has  been  detained.  The  subject  has  been  recently  ablv 
considered  by  Puech,i  who  admits  two  varieties  of  ovarian  pregnane}^, 
according  as  the  foetus  has  developed  in  a  vesicle  which  has  remained 
open,  or  in  one  which  has  closed  immediately  after  fecundation.  He 
considers  that  most  cases  of  so-called  ovarian  pregnancy  are  either 
dermoid  cysts,  ovario-tubal  pregnancies,  or  abdominal  pregnancies 
in  which  the  placenta  is  attached  to  the  ovary,  and  that  even  in  the 
rare  cases  of  true  ovarian  pregnancies,  the  progress  and  results  do 
not  differ  from  that  of  abdominal  pregnancy.  While,  therefore,  it  is 
impossible  to  deny  the  existence  of  ovarian  pregnancy,  it  must  be 
considered  to  be  a  very  rare  and  exceptional  variety,  which,  as  far 

'  Annal.  de  Gynjec,  July,  1878. 


168  PREGNANCY. 

as  treatment  and  results  are  concerned,  does  not  differ  from  tubal 
or  abdominal  gestation.  4th.  There  are  two  rare  varieties  in  which 
an  ovum  is  developed  either  in  the  supplementary  horn  of  a  hi-lohed 
uterus^  or  in  a  hernial  sac. 

For  the  sake  of  clearness,  we  may  place  these  varieties  of  extra- 
uterine gestation  in  the  following  tabular  form  : — 

1st.   Tubal — 

(a)  Interstitial,  (6)  Tubo-ovarian. 

2d.  Abdominal — 

(a)  Primary,  ilj)  Secondary. 

3d.   Ovarian. 

4th.  In  hi-lohed  uterus^  hernial.^  etc. 

Causes. — The  etiology  of  extra-uterine  foetation  in  any  individual 
case  must  necessarily  be  almost  always  obscure.  Broadly  speaking, 
it  may  be  said  that  extra-uterine  foetation  may  be  produced  by  any 
condition  which  prevents,  or  renders  difficult,  the  passage  of  the 
ovule  to  the  uterus,  while  it  does  not  prevent  the  access  of  the 
spermatozoa  to  the  ovule.  Thus  inflammatory  thickening  of  the 
coats  of  the  Fallopian  tubes  by  lessening  their  calibre,  but  not  suffi- 
ciently so  to  prevent  the  passage  of  the  spermatozoa,  may  interfere 
with  the  movements  of  the  tube  which  propel  the  ovum  forward,  and 
so  cause  its  arrest.  A  similar  effect  may  be  produced  by  various 
morbid  conditions,  such  as  inflammatory  adhesions,  from  old-stand- 
ing peritonitis,  pressing  on  the  tube ;  obstruction  of  its  calibre  by 
inspissated  mucus  or  small  poh^poid  growths;  the  pressure  of  uterine 
or  other  tumors,  and  the  like.  The  fact  that  extra-uterine  preg- 
nancies occur  most  frequently  in  multiparas,  and  comparatively  rarely 
in  women  under  thirty  years  of  age,  tends  to  show  that  these  con- 
ditions, which  are  clearly  more  likely  to  be  met  with  in  such  women 
than  in  young  primiparas,  have  considerable  influence  in  its  causation. 
A  curiously  large  proportion  of  cases  occur  in  women  who  have 
either  been  previously  altogether  sterile,  or  in  whom  a  long  interval 
of  time  has  elapsed  since  their  last  pregnancy.  The  disturbing 
effects  of  fright,  either  during  coition  or  a  few  days  afterwards,  have 
been  insisted  on  by  many  authors  as  a  possible  cause.  Numerous 
cases  of  this  kind  are  recorded  ;  and.  although  the  influence  of 
emotion  in  the  production  of  this  condition  is  not  susceptible  of  proof, 
it  is  not  difficult  to  imagine  that  spasms  of  the  Fallopian  tubes  might 
be  produced  in  this  way,  which  would  either  interfere  with  the 
passage  of  the  ovum,  or  direct  it  into  the  abdominal  cavily.  The  oc- 
currence of  abdominal  pregnancy  is  probably  less  difficult  to  account 
for  if  we  admit,  with  Coste,  that  the  ovule  becomes  impregnated  on  the 
surface  of  the  ovary  itself,  for  there  must  be  very  many  conditions 
which  prevent  the  proper  adaptation  of  the  fimbriated  extremity  of 
the  tube  to  the  surface  of  the  ovary,  and  failing  this,  the  ovum  must 
of  necessity  drop  into  the  abdominal  cavity.  Kiwisch  has  pointed  out 
that  this  is  particularly  apt  to  occur  when  the  Graafian  follicle  de- 
velops on  the  posterior  surface  of  the  ovary ;  and,  indeed,  it  is  proba- 
ble that  it  may  be  of  common  occurrence,  and  that  the  comparative 
rarity  of  abdominal  pregnancy  is  due  to  the  difficulty  with  which  the 


ALNORMAL    rUEUNANCY. 


169 


impregnated  ovule  engrafts  itself  on  the  surrounding  viscera.  Im- 
pregnation may  aetualJy  occur  in  the  abdominal  cavity  itself,  of  which 
Keller^  relates  a  remarkable  instance.  In  this  case  Koeberle  had  re- 
moved the  body  of  the  uterus  and  part  of  the  cervix,  leaving  the 
ovaries.  In  the  portion  of  the  cervix  that  remained  there  was  a  fistu- 
lous aperture  opening  into  the  abdominal  cavity,  through  wdiich  semeu 
passed  and  produced  an  abdominal  gestation.  Several  curious  cases 
are  also  recorded,  which  have  given  rise  to  a  good  deal  of  discussion,  in 
which  a  tubal  pregnancy  existed  while  the  corpus  luteum  was  on  the 
opposite  side  (Fig.  77).      The  most  probable  explanation,  however,  is 

Frr:.  77. 


Tubal  Pregnancy,  witli  the  Corpus  Luteum  in  the  Ovaty  of  the  opposite  side.    The  Decidua  is 
represented  ia  the  process  of  detachment  from  the  Uterine  Cavity. 


that  the  fimbriated  extremity  of  the  tube  in  which  the  ovum  Avas  found 
had  twisted  across  the  abdominal  cavity  and  grasped  the  opposite 
ovary,  in  this  waj^,  perhaps,  producing  a  flexion  Avhich  impeded  the 
progress  of  the  ovum  it  had  received  into  its  canal.  Tyler  Smith 
suggested  that  such  cases  might  be  explained  by  supposing  that  the 
ovum,  after  reaching  the  uterus,  failed  to  graft  itself  in  the  mucous 
membrane,  but  found  its  way  into  the  opposite  Fallopian  tube. 
KussmauP  thinks  that  such  a  passage  of  the  ovum  across  the  uterine 
cavity  may  be  caused  by  muscular  contraction  of  the  uterus,  occurring 
shortly  after  conception,  squeezing  the  yet  free  ovum  upwards 
towards  the  opening  of  the  opposite  tube,  and  possibly  into  the  tube 
itself. 

The  history  and  progress  of  cases  of  extra-iiterine  pregnancy  are 
materially  different  according  to  their  site,  and,  for  practical  pur- 
poses, we  may  consider  them  as  forming  two  great  classes  :  the  tubal 
(with  its  varieties),  and  the  abdominal. 

Tahal  Pref/nancies. — When  the  ovum  is  arrested  in  any  part  of  the 
Fallopian  tube  the  chorion  soon  commences  to  develop  villi,  just  as 
in  ordinary  pregnancy,  which  engraft  themselves  into  the  mucous 
lining  of  the  tube,  and   fix   the  ovum    in  its  new  position.      The 


'  Des  Grosseses  Extra-uterines,  Paris,  1872. 
2  Mon.  f.  Geburt,  Oct.  1862. 


12 


170 


PREG^v  ANCY, 


mucous  membrane  becomes  liypertropliied,  much  in  tlie  same  way  as 
that  of  the  uterus  under  similar  circumstances  ;  so  tliat  it  becomes 
developed  into  a  sort  of  pseudo-decidua.  Inasmuch,  however,  as  the 
raucous  coat  of  the  tubes  is  not  furnished  with  tubular  glands,  a  true 
decidua  can  scarcely  be  said  to  exist,  nor  is  there  any  growth  of 
membrane  around  the  ovum  analogous  to  the  decidua  refiexa.  The 
ovum  is,  therefore,  comparatively  speaking,  loosely  attached  to  its 
abnormal  situation,  and  hence  hemorrhage  from  laceration  of  the 
chorion  villi  can  very  readily  take  place. 

It  is  seldom  that  any  development  of  the  cliorion  villi  into  distinct 
placental  structure  is  observed ;  this  is  probably  owing  to  the  fact, 
that  laceration  and  death  generally  occur  before  the  period  at  whicli 
the  placenta  is  normally  formed.  The  muscular  coat  of  the  tube 
soon  becomes  hypertrophied,  and,  as  the  size  of  the  ovum  increases, 
the  fibres  are  separated  from  each  other,  so  that  the  ovum  protrudes 
at  certain  points  through  them,  and  at  these  it  is  only  covered  by  the 
stretched  and  attenuated  mucous  and  peritoneal  coats  of  the  tube. 
At  this  time  the  tubal  pregnancy  forms  a  smooth  oval  tumor,  which, 
as  a  rule,  has  not  formed  any  adhesions  to  the  surrounding  structures 
(Fig.  78).     The  part  of  the  tube  unoccupied  by  the  ovum  may  be 


Fig.  78. 


Tubal  Pregnancy.     (From  a  Specimen  in  the  Museum  of  King's  College.) 

found  unaltered,  and  permeable  in  both  directions;  or,  more  fre- 
quently, it  becomes  so  stretched  and  altered  that  its  canal  cannot  be 
detected.  Most  frequently  it  is  that  part  of  the  tube  nearest  the 
uterus  which  cannot  be  raade  out.  The  condition  of  the  uterus  in 
this,  as  in  other  forms  of  extra-uterine  pregnancy,  has  been  the  sub- 
ject of  considerable  discussion.     It  is  now  universally  admitted  that 


ABNORMAL    PREGNANCY.  171 

the  uterus  undergoes  a  certain  amount  of  sympathetic  engorgement, 
the  cervix  becomes  softened,  as  in  natural  pregnancy,  and  the 
mucous  membrane  develops  into  a  true  decidua.  In  many  cases  the 
decidua  is  found  on  post-mortem  examination,  in  others  it  is  not; 
and  hence  the  doubts  that  some  have  expressed  as  to  its  existence. 
The  most  reasonable  explanation  of  its  absence  is  that  given  by 
Daguet,^  who  has  shown  that  it  is  far  from  uncommon  for  the  uterine 
decidua  to  be  thrown  off  en  masse  during  the  hemorrhagic  dis- 
charges which  so  frequently  precede  the  fatal  issue  of  extra-uterine 
gestation. 

Interstitial  and  False  Ovarian  Pregnancy. — "When  the  ovum  is 
arrested  in  that  portion  of  the  tube  passing  through  the  uterus,  in 
so- called  interstitial  pregnancy,  the  muscular  fibres  of  the  uterus 
become  stretched  and  distended,  and  form  the  outer  covering  of  the 
ovum.  When,  on  the  other  hand,  the  site  of  arrest  is  in  the  fimbri- 
ated extremity  of  the  tube,  the  containing  cyst  is  formed  partly  of 
the  fimbriae  of  the  tube,  partly  of  ovarian  tissue ;  hence  it  is  much 
more  distensible,  and  the  pregnancy  may  continue  without  laceration 
to  a  more  advanced  period,  or  even  to  term,  so  that  when  the  ovum 
is  placed  in  this  situation,  the  case  much  more  nearly  resembles  one 
of  abdominal  pregnancy. 

Period  at  which  Rwpture  Occurs. — The  termination  of  tubal  preg- 
nancy, in  the  immense  majority  of  cases,  is  death,  produced  by  lace- 
ration giving  rise  either  to  internal  hemorrhage,  or  to  subsequent 
intense  peritonitis.  Rupture  usually  occurs  at  an  early  period  of 
pregnancy,  most  generally  from  the  fourth  to  the  twelfth  Aveek,  rarely 
later.  However,  a  few  instances  are  recorded  in  which  it  did  not 
take  place  until  the  fourth  or  fifth  month,  and  Saxtorph  and  Spiegel- 
berg  have  recorded  apparentlj^  authentic  cases  in  which  the  preg- 
nancy advanced  to  term  without  laceration.  It  is  generally  effected 
by  distension  of  the  tube,  which  at  last  yields  at  the  point  which  is 
most  stretched;  and  sometimes  it  seems  to  be  hastened  or  deter- 
mined by  accidental  circumstances,  such  as  a  blow  or  fall,  or  the 
excitement  of  sexual  intercourse. 

Symptoms  of  Rupture. — The  symptoms  accompanying  rupture  are 
those  of  intense  collapse,  often  associated  with  severe  abdominal 
pain,  produced  by  the  laceration  of  the  cyst.  The  patient  will  be 
found  deadly  pale,  with  a  small,  thready,  and  almost  imperceptible 
pulse,  perhaps  vomiting,  but  with  mental  faculties  clear.  If  the 
hemorrhage  be  considerable,  she  may  die  without  any  attempt  at  re- 
action. Sometimes,  however — and  this  generally  occurs  in  cases  in 
which  the  tube  tears,  the  ovum  remaining  intact — -the  hemorrhage 
may  cease  on  account  of  the  ovum  protruding  through  the  aperture, 
and  acting  as  a  plug.  The  patient  may  then  imperfectly  rally,  to  be 
again  prostrated  by  a  second  escape  of  blood,  which  proves  fatal. 
If  the  loss  of  blood  is  not  of  itself  sufficient  to  cause  death  from 
shock  and  anemia,  the  fatal  issue  is  generally  only  postponed,  for  the 
effused  blood  soon  sets  up  a  violent  general  peritonitis,  which  rapidly 

'  Annales  de  Gyiiecologie,  May,  1874. 


172 


PREGNANCY, 


carries  off  the  patient.  If  she  should  survive  the  second  danger,  the 
case  is  transformed  into  one  of  abdominal  pregnancy,  the  foetus 
becoming  surrounded  by  a  capsule  produced  by  inflammatory  exuda- 
tion (Fig.  79).  The  case  is  then  subjected  to  the  rules  of  treatment 
presently  to  be  discussed  when  considering  that  variety  of  extra- 
uterine gestation. 


Fig.  79. 


Extra-uterine  Pregnancy  at  term  of  the  Tubo-Ovarian  variety.     (After  a  Case  of  Dr.  A.  Sibley 

CampbeU's.) 

Diagnosis. — -The  possibility  of  diagnosing  tubal  gestation  before 
rupture  occurs  is  a  question  of  great  and  increasing  interest,  from 
the  fact  that,  could  its  existence  be  ascertained,  we  might  very  fairly 
hope  to  avert  the  almost  certainly  fatal  issue  which  is  awaiting  the 
patient.  Unfortunately,  the  symptoms  of  tubal  pregnancy  are 
always  obscure,  and  too  often  death  occurs  without  the  slightest 
suspicion  as  to  the  nature  of  the  case  having  arisen.  In  the  first 
place,  it  is  to  be  observed  that  all  the  usual  sympathetic  disturbances 
of  pregnancy  exist:  the  breasts  enlarge,  the' areolae  darken,  and 
morning  sickness  is  present.  There  is  also  an  arrest  of  menstruation  ; 
but,  after  the  absence  of  one  or  more  periods,  there  is  often  an  irreg- 
ular hemorrhagic  discharge.  This  is  an  important  symptom,  the 
value  of  which  in  indicating  the  existence  of  tubal  pregnancy  has  of 
late  years  been  much  dwelt  upon  by  various  authors,  both  in  this 


ABNORMAL    PREGNANCY.  173 

country  and  abroad.  Barnes  attributes  it  to  partial  detachment  of 
the  chorion  villi,  produced  by  the  ovum  growing  out  of  proportion 
to  the  tube  in  wiiich  it  is  contained.  Whether  this  is  the  correct 
explanation  or  not,  it  is  a  fact  that  irregular  hemorrhage  very  gene- 
rally precedes  the  laceration  for  several  days  or  more.  Accompanying 
this  hemorrhage  there  is  almost  always  more  or  less  abdominal  pain, 
produced  by  the  stretching  of  the  tissues  in  which  the  ovum  is 
placed,  and  this  is  sometimes  described  as  being  of  very  intense  and 
crampy  character.  If,  then,  we  meet  with  a  case  in  which  the  symp- 
toms of  early  pregnancy  exist,  in  which  there  are  irregular  losses  of 
blood,  possibly  discharge  of  membranous  shreds,  and  abdominal  pain, 
a  careful  examination  should  be  insisted  on,  and  then  the  true  natuj-e 
of  the  case  may  possibly  be  ascertained.  Should  extra-uterine  foetation 
exist,  we  should  expect  to  find  the  uterus  somewhat  enlarged,  and 
the  cervix  softened,  as  in  early  pregnancy,  but  both  these  changes 
are  doubtless  generally  less  marked  than  in  normal  pregnanc3^ 
This  fact  of  itself,  however,  is  of  little  diagnostic  value,  for  sligiit 
difference  of  this  kind  must  always  be  too  indefinite  to  justify  a 
positive  opinion. 

Presence  of  a  Peri-uterine  Tumor. — The  existence  of  a  peri-uterine 
tumor,  rounded  or  oval  in  outline,  and  producing  more  or  less  dis- 
placement of  the  uterus,  in  the  direction  opposite  to  that  in  which 
the  tumor  is  situated,  may  point  to  the  existence  of  tubular  foetation. 
By  bimanual  examination,  one  hand  depressing  the  abdominal  wall, 
while  the  examining  finger  of  the  other  acts  in  concert  with  it  either 
through  the  vagina  or  rectum,  the  size  and  relations  of  the  growth 
may  be  mads  out.  There  are  various  conditions,  which  give  rise  to 
very  similar  physical  signs,  such  as  small  ovarian  or  fibroid  growths, 
or  the  effusion  of  blood  around  the  uterus  ;  and  the  differential  diag- 
nosis must  always  be  very  difficult,  and  often  impossible.  A  curious 
example  of  the  difficulties  of  diagnosis  is  recorded  by  Joulin,  in  which 
Haguier,  and  six  or  seven  of  the  most  skilled  obstetricians  of  Paris, 
agreed  on  the  existence  of  extra-uterine  pregnancy,  and  had,  in  con- 
sultation, sanctioned  an  operation,  when  the  case  terminated  by 
abortion,  and  proved  to  be  a  natural  pregnancy.  The  use  of  the 
uterine  sound,  which  might  aid  in  clearing  up  the  case,  is  necessarily 
contra-indicated  unless  uterine  gestation  is  certainly  disproved. 
Hence  it  must  be  admitted  that  positive  diagnosis  must  almost  always 
be  very  difficult.  So  that  the  most  we  can  say  is,  that  when  the 
general  signs  of  early  pregnancy  are  present,  associated  with  the 
other  symptoms  and  signs  alluded  to,  the  suspicion  of  tubal  preg- 
nancy may  be  sufficiently  strong  to  justify  us  in  taking  such  action 
as  may  possibly  spare  the  patient  the  necessarily  fatal  consequence 
of  rupture. 

Treatment. — If  the  diagnosis  were  quite  certain,  the  removal  of 
the  entire  Fallopian  tube  and  its  contents  by  abdominal  section 
would  be  quite  justifiable,  and  probably  would  .neither  be  more 
difficult,  nor  more  dangerous,  than  ovariotomy ;  for,  at  this  stage  of 
extra- uterine  foetation,   there  are    no   adhesions   to  complicate  the 


174:  PREGNANCY. 

operation.  As  yet,  however,  the  uncertainty  of  the  diagnosis  has 
prevented  the  adoption  of  the  practice. 

[In  1816,  Dr.  John  King,^  ot  Edisto  Island,  South  Carolina,  ope- 
rated upon  a  case  of  extra-uterine  pregnancy  by  the  vaginal  section, 
and  saved  both  mother  and  child.  The  placenta  was  removed,  but 
there  does  not  appear  to  have  been  any  hemorrhage. — Ed.] 

Opening  of  the  Sac  hy  the  Galvano- caustic  Knife. — Dr.  Thomas,  of 
New  York,2  has  recently  recorded  a  most  instructive  case,  in  which 
he  saved  the  life  of  the  patient  by  a  bold  and  judicious  operation. 
The  nature  of  the  case  was  rendered  pretty  evident  by  the  signs 
above  described,  and  Thomas  opened  the  cyst  from  the  vagina  by  a 
platinum  knife,  rendered  incandescent  by  a  galvano-caustic  battery, 
by  which  means  he  hoped  to  prevent  hemorrhage.  Through  the 
opening  thus  made  he  removed  the  foetus.  In  subsequently  attempt- 
ing to  remove  the  placenta  very  violent  hemorrhage  took  place, 
which  was  only  arrested  by  mjecting  the  cyst  with  a  solution  of 
persulphate  of  iron.  The  remains  of  the  placenta  subsequently  came 
away  piecemeal,  after  an  attack  of  septicaemia,  which  was  kept 
within  bounds  by  freely  washing  out  the  cyst  with  antiseptic  lotion, 
the  patient  eventually  recovering.  If  I  might  venture  to  make  a 
criticism  on  a  case  followed  by  so  brilliant  a  success,  it  would  be 
that,  in  another  instance  of  this  kind,  it  would  be  safer  to  follow  the 
rule  so  strictly  laid  down  with  regard  to  gastrotomy  in  abdominal 
pregnancies,  and  leave  the  placenta  untouched,  trusting  to  the  injec- 
tion of  antiseptics,  and  the  thorough  drainage  of  the  cyst,  to  prevent 
mischief. 

[In  a  second  operation,  performed  on  May  10,  1876,  in  a  case  of 
secondary  abdominal  pregnancy.  Dr.  Thomas^  operated  through  the 
linea  alba,  and  removed  a  female  foetus  weighing  six  pounds,  fifteen 
ounces.  The  funis  was  traced  to  the  left  iliac  fossa,  where  it  was 
apparently  inserted  into  the  peritoneum,  and  no  placenta  was  dis- 
cernible. The  cord  was  cut  off  at  its  origin,  and  the  wound  closed, 
except  at  its  lower  part,  which  was  kept  open  by  a  glass  tube.  The 
woman's  pulse  before  the  operation  was  120,  and  fell  to  107  at  the 
end  of  the  first  week ;  temperature  was  always  100°  and  upwards, 
but  in  the  middle  of  the  fourth  week  it  rose  to  103°-104°,  and  the 
pulse  to  130.  The  placenta  was  found  presenting  at  the  opening  in 
the  abdomen,  and  was  removed  with  dressing  forceps.  It  was  of  the 
ordinary  diameter,  and  had  a  shrivelled  appearance.  The  removal 
afforded  a  decided  relief,  and  the  temperature  fell  within  three  hours. 
Antiseptic  injections  were  freely  used  in  the  treatment  of  the  case, 
and  the  patient  made  a  good  recovery. 

The  success  of  this  operation,^  may  be  said  to  have  been  in  a  meas- 
ure, the  saving  of  a  similar  case  in  this  city,  for  when  Dr.  Walter  F. 
Atlee  was  shown  the  report,  he  finally  decided  to  operate  in  the  case 
of  a  M^oman  Avho  had  carried  a  foetus  for  thirteen  months,  and  in 

[•  New  York  Med.  Repos.,  1817,  p.  388.] 

2  New  York  Med.  Journ.,  June,  1875. 

\}  Am.  Journ.  of  Obstetrics,  vol.  ix.  p.  655,  1876.] 

[^  Am.  Jour,  of  Med.  Sci.  Oct.  1878,  p.  321,  reported  by  Ed.] 


ABNORMAL    PREGNANCY.  175 

whom  certain  nervous  and  vascular  disturbances  were  indicative  of 
dano-er,  although  she  bcre  the  appearance  of  good  health.  Laparot- 
omy was  performed  on  May  18th.  1878,  and  the  patient  went  home  six 
mifes,  at  the  end  of  twenty-six  days.  I  have  seen  her  repeatedly, 
and  she  now  weighs  more  than  at  any  time  in  her  life.  This  is  the 
only  instance  of  the  operation  in  Philadelphia. 

The  advice  given  by  the  author  in  regard  to  the  non-removal  of 
the  placenta  was /?rs^  urged  upon  the  medical  profession  in  1791,  by 
Mr.  William  Truvnbull  in  a  paper  read  before  the  Medical  Society  of 
London  ;  and  again  in  1795,  in  a  letter^  from  the  late  Dr.  James  Mease, 
of  Philadelphia,  to  Dr.  Lettsom,  of  London,  in  which  he  reported  an 
operation  by  Dr.  Charles  McKnight,  of  New  York,  very  similar  to 
this  of  Dr.  Thomas,  and  ending  favorably  to  the  woman.  The 
remarks  of  Dr.  Mease  on  the  impropriety  of  removing  the  placenta 
were  read  before  the  same  society,  and  concurred  in  by  some  of  the 
members  present. 

It  is  a  little  remarkable,  that  the  opinion  of  Dr.  Mease  originated 
in  an  accident  which  occurred  in  the  operation  of  Dr.  McKnight,  by 
which  the  funis  was  ruptured,  and  in  consequence  of  which,  the 
placenta,  which  was  outside  of  the  cyst,  could  not  be  found  for 
removal.  The  value  of  this  discovery,  appears  to  have  been  lost  to 
the  profession  for  a  long  term  of  years,  as  many  authors  have  ob- 
jected to  the  operation  because  of  the  danger  of  removing  the  pla- 
centa. 

Prof  T.  G^illard  Thomas^  before  mentioned,  has  perhaps  had  as 
successful  an  experience  in  the  operation  of  laparotomy  for  the  re 
moval  of  extra  uterine  foetuses,  as  any  man  either  in  Europe  or 
America :  having  operated  in  this  form  three  times  since  the  begin- 
ning of  May,  1876,  with  a  favorable  result  in  each  case.  This  shows 
that  the  operation  is  much  less  dangerous  to  life  than  was  for  a  long 
period  believed.  The  day  of  "  waiting  for  iinpostkumation  to  tahe 
place'''  is  in  a  measure  passing  away,  and  the  wiser  plan  of  removing 
the  foetus  where  the  condition  of  the  woman  is  indicative  of  danger 
is  becoming  recognized  as  proper  and  advisable.  It  is  very  well  to 
wait  for  a  pointing  to  take  place  in  some  cases,  but  we  must  remem- 
ber that  in  many,  to  delay  is  to  lose  the  patient.  There  have  been 
several  cases  illustrating  this  latter  experience  within  a  few  yeai'S  in 
Philadelphia,  and  the  actors  engaged,  have  in  consequence  very  ma- 
terially changed  their  conservative  views. — Ed.] 

Means  of  Dpstroying  the  Vitality  of  the  Fcetus. — Another  mode  of 
managing  these  cases  is  to  destroy  the  foetus,  so  as  to  check  its 
further  growth,  in  the  hope  that  it  may  remain  inert  and  passive 
within  its  sac.  Various  operations  have  been  suggested  and  prac- 
tised for  this  purpose.  Thus  needles  have  been  introduced  into  the 
tumor,  through  which  currents  of  electricity  have  been  passed,  either 
the  continuous  current,  or,  as  has  been  suggested  by  Duchenne,  a 
spark  of  Franklinic  electricitv      Hicks,  Allen    and  others  have  en- 

\}  Memoirs  of  Merl.  Soc.  London,  vol.  iv.  p.  342,  1795.] 

[2  Am.  Jour,  of  Med.  Sci.,  Oct.  1878,  p.  321,  and  Jan.  1879,  p.  17.— Ed.] 


176  PREGNANCY. 

deavored  to  destroy  the  fetus  by  passing  an  electro-magnetic  cur- 
rent through  it  by  means  of  a  needle.  In  a  case  reported  by  Dr. 
Bachetti,  in  which  the  continuous  current  was  used,  the  growth  of 
the  ovum  was  arrested,  and  the  patient  recovered.  The  same  result, 
however,  would  probably  have  followed  the  simple  puncture  of  the 
cyst.  This  has  been  successfully  practised  on  several  occasions 
either  with  a  small  trocar  and  canula,  or  with  a  simple  needle.  A 
very  interesting  case,  in  which  the  development  of  a  two  months' 
tubal  gestation  was  arrested  in  this  way,  is  recorded  by  Greenhalgh,^ 
and  another  by  Martin,  of  Berlin.^  Joulin  suggested  that  not  only 
should  the  cyst  be  punctured,  but  that  a  solution  of  morphia  should 
be  injected  into  it,  which,  by  its  toxic  influence,  would  insure  the 
destruction  of  the  foetus.  Other  means  proposed  for  effecting  the 
same  object,  such  as  pressure,  or  the  administration  of  toxic  remedies 
by  the  mouth,  are  too  far  uncertain  to  be  relied  on.  The  simplest 
and  most  effectual  plan  would  be  to  introduce  the  needle  of  an 
aspirator,  by  which  the  liquor  amnii  would  be  drawn  off,  and  the 
further  growth  of  the  foetus  effectually  prevented.  Parry ,3  indeed, 
is  opposed  to  this  practice,  and  has  collected  several  cases  in  which 
the  puncture  of  the  cyst  was  followed  by  fatal  results,  either  from 
hemorrhage  or  septicaemia.  In  these,  however,  an  ordinary  trocar 
and  canula  were  probably  emploj^ed,  which  would  necessarily  admit 
air  into  the  sac.  It  is  difficult  to  imagine  that  a  fine  hair-like  aspi- 
rating needle,  rendered  properly  antiseptic  by  carbolic  acid,  could 
have  any  injurious  results;  and  it  could  do  no  harm,  even  if  an 
error  of  diagnosis  had  been  made,  and  the  suspected  extra-uterine 
foetation  turned  out  to  be  some  other  sort  of  growth.  If  the  aspi- 
rator proves  that  an  extra-uterine  foetation  exists,  then,  if  the  cyst 
be  of  any  considerable  size,  and  the  pregnancy  advanced  beyond 
the  second  month,  we  might,  if  deemed  advisable,  resort  to  a  more 
radical  operation,  such  as  that  so  successfully  practised  by  Thomas. 

Treatment  u-Jien  Riq:)tnre  has  Occurred.- — When  the  chance  of  arrest- 
ing the  growth  of  a  tubular  foetation  has  never  arisen,  and  we  first 
recognize  its  existence  after  laceration  has  occurred,  and  the  patient 
is  collapsed  from  hemorrhage,  what  course  are  we  to  pursue?  Plith- 
erto  all  that  ever  has  been  done  is  to  attempt  to  rally  the  patient  by 
stimulants,  and,  in  the  unlikely  event  of  her  surviving  the  imme- 
diate effects  of  laceration,  endeavoring  to  control  the  subsequent 
peritonitis,  in  the  hope  that  the  effused  blood  may  become  absorbed, 
as  in  pelvic  hematocele.  This  is,  indeed,  a  frail  reed  to  rest  upon, 
and  when  laceration  of  a  tubal  gestation,  advanced  beyond  a  month, 
has  occurred,  death  has  been  the  most  certain  result.  It  is  supposed 
by  Bernutz,  and  his  opinion  is  shared  by  Barnes,  that  rupture  which 
does  not  prove  fatal,  is  probably  not  very  rare  in  the  first  few  days 
of  extra-uterine  gestation,  and  that  it  is  not  an  uncommon  cause  of 
certain  forms  of  pelvic  hgematocele.  It  has  more  than  once  been  sug- 
gested that  it  would  be  perfectly  justifiable  when  laceration  has  oc- 

'  Lancet,  1867.  2  Monat.  f.  Geburt,  1868. 

*  Parry  on  Extra-Uterine  Pregnancy,  p.  204. 


ABNORMAL    PREGNANCY.  177 

curred  to  perform  gastrotomy,  to  sponge  away  the  effused  blood,  and 
to  place  a  ligature  around  the  lacerated  tube'and  remove  it,  with  its 
contents.  This  would  no  doubt  be  a  bold  and  heroic  procedure,  but 
no  one  who  is  acquainted  with  the  triumphs  of  modern  abdominal 
surgery  can  say  that  it  would  be  either  impossible  or  hopeless.  The 
sponging  out  of  effused  blood  from  the  abdominal  cavity  is  an  every- 
day procedure  in  ovariotomy,  nor  is  there  any  apparent  difficulty  in 
ligaturing  and  removing  the  sac  of  the  extra-uterine  pregnancy,  for, 
as  a  rule,  there  are  no  adhesions  formed  to  the  surrounding  parts. 
The  history  of  these  cases  shows  that  death  does  not  generally  follow 
rupture  for  some  hours,  so  that  there  would  be  usually  time  for  the 
operation,  and  the  extreme  prostration  might  be,  perhaps,  tempo- 
rarily counteracted  by  transfusion.  Pressure  on  the  abdominal  aorta, 
resorted  to  when  the  patient  is  lirst  seen,  might  possibly  be  employed 
with  advantage  to  check  further  hemorrhage,  until  the  question  of 
operation  is  decided.  We  must  remember  that  the  alternative  is 
death  and  hence  any  operation  which  Avould  afford  the  slightest  hope 
of  success  Avould  be  perfectly  justifiable.  I  cannot,  therefore,  agree 
with  those  who  hold  that  because  the  chances  of  success  are  so  small, 
the  operation  should  not  be  tried ;  and  I  do  not  doubt  that  it  will 
yet  fall  to  the  lot  of  some  one,  by  this  means,  to  snatch  a  patient 
from  the  jaws  of  death,  and  still  further  to  extend  the  successes  of 
abdominal  surgery. 

[The  great  obstacle  to  such  a  procedure,  is  the  difficulty  or  un- 
certainty of  diagnosis.  One  man  of  large  experience  in  gynaecological 
operations  may  be  quite  j)ositive  of  the  condition,  and  be  willing  to 
operate,  when  he  is  opposed  in  opinion  and  decision  by  a  consultation 
of  several  medical  brethren.  A  case  in  point  occurred  recently  in 
one  of  our  large  cities,  where  the  patient  Avas  examined  by  several 
physicians,  one  of  whom  Avas  anxious  to  operate  but  Avas  overruled — 
the  lady  died  in  sixty  hours,  of  a  sloAvly  oozing  hemorrhage  from  a 
small  ruptured  Fallopian  cyst  as  proved  by  autopsy,  and  the  gynse- 
cologist  proposing  to  operate  was  confident  that  the  bleeding  might 
have  been  readily  arrested  by  laparotomy,  and  a  clamp  or  ligation. 
—Ed.] 

Abdominal  Pregnancy. — In  the  second  of  the  tAvo  classes  into  which, 
for  practical  convenience,  Ave  have  divided  extra-uterine  gestation 
the  ovum  is  developed  in  the  abdominal  cavity.  It  is  as  yet  an  open 
question  whether  in  some  cases  the  pregnancy  is  primarily  abdominal 
or  not.  Barnes  believes  that  it  probably  never  is  so,  on  account  of 
the  difficulty  of  admitting  that  so  minute  a  body  as  the  ovum  should 
be  able  to  fix  itself  on  the  smooth  peritoneal  surface.  He  therefore 
thinks  that  all  abdominal  pregnancies  are  primarily  either  tubal  or. 
ovarian,  the  sac  in  which  they  Avere  contained  liaAdng  given  way, 
and  the  ovum  having  retained  its  vitality  through  partial  attach- 
ment to  the  original  sac.  This  theory  is  opposed  to  that  of  the  ma- 
jority of  writers,  and,  although  it  may  perhaps  render  the  facts  less 
difficult  to  understand,  it  is  purely  hypothetical.  There  is  no  evi- 
dence to  show  that  in  most  cases  there  is  an  early  laceration  of  a 
tubal  or  ovarian  sac.     That  the  chorion  villi  do  graft  themselves 


178  PREGNANCY. 

upon  the  surrounding  peritoneum  is  certain,  and  is  observed  in  all 
cases  of  abdominal  gestation.  It  is  not  more  difficult  to  imagine 
them  doing  this  from  their  very  first  development  than  a  little  later; 
for  it  must  be  allowed  that  if  such  laceration  does  occur,  in  most 
cases  it  can  only  be  when  pregnancy  is  verv  slightly  advanced.  On 
the  whole,  therefore,  it  seems  not  unreasonable  to  admit  the  usual 
explanation  of  these  cases,  that  the  ovule,  already  impregnated, 
escaped  the  grasp  of  the  Fallopian  tube,  and  fell  into  the  abdominal 
cavity,  where  it  rooted  itself  and  developed.  Some  have,  indeed, 
supposed  that  abdominal  pregnancy  may  occasionally  arise  in  conse- 
quence of  spermatozoa  finding  their  way  into  the  peritoneal  cavity, 
and  there  meeting  and  impregnating  an  ovule  discharged  from  the 
Graafian  follicle.  Such  an  event  one  would  suppose  to  be  almost  im- 
possible, but  Koeberld's  case,  already  quoted,  proves  that  it  has  actu- 
ally occurred.  The  probability  is  that  it  is  by  no  means  rare  for  im- 
pregnated ovules  to  drop  into  the  peritoneal  cavity,  and  that  the 
majority  of  those  that  do  so  perish  without  doing  any  harm.  "When 
they  do  survive,  however,  the  chorion  villi  sprout,  attach  themselves 
to  the  surrounding  structures,  and  eventually  develop  into  a  placenta. 
The  mode  in  which  the  chorion  villi  are  attached,  and  the  arrange- 
ment of  the  maternal  bloodvessels,  have  never  yet  been  worked  out, 
and  would  form  a  very  interesting  subject  for  investigation.  The 
precise  seat  of  attachment  varies,  and  the  placenta  has  been  found 
fixed  to  most  of  the  abdominal  viscera,  either  those  contained  in  the 
pelvis  proper,  or  it  may  be  the  intestines,  or  to  the  iliac  fossa ;  most 
frequently,  apparently,  the  ovum  finds  its  way  into  the  retrouterine 
cul-de-sac. 

Formation  of  a  Cyst  round  the  Ovv.m. — The  subsequent  changes 
vary  much.  In  the  large  majority  of  cases  the  ovum  produces  con- 
siderable irritation,  resulting  in  the  exudation  of  plastic  material, 
which  is  thrown  round  it,  so  as  to  form  a  secondary  cyst  or  capsule, 
in  which  maternal  vessels  are  largely  developed,  and  which  stretches, 
pari  passu,  with  the  growth  of  the  ovum  (Fig.  80).  The  density  and 
strength  of  this  cyst  are  found  to  be  very  different  in  different  cases ; 
sometimes  it  forms  a  complete  and  strong  covering  to  the  ovum,  at 
others  it  is  very  thin  and  only  partially  developed,  but  it  is  rarely 
entirely  absent.  As  there  is  ample  space  for  the  development  of  the 
ovum,  and  as  the  secondary  cyst  generally  stretches  and  grows  along 
with  it,  most  cases  of  abdominal  pregnancy  progress  without  any 
very  remarkable  symptoms,  beyond  occasional  severe  attacks  of  pain, 
until  the  full  term  of  pregnancy  has  been  reached.  Sometimes,  how- 
ever, the  cyst  lacerates,  and  there  is  an  escape  of  blood  into  the 
abdominal  cavity,  accompanied  by  more  or  less  prostration  and  col- 
lapse, which  may  prove  fiatal,  but  from  which  the  patient  more  gen- 
erally rallies.  The  foetus,  now  dead,  will  remain  in  the  abdomen, 
and  will  undergo  changes  and  produce  results  similar  to  those  which 
we  shall  presently  described  as  occurring  in  cases  progressing  to  the 
full  period. 

Pseudo-lahor  sometimes  comes  on. — In  most  cases  at  the  natural 
termination   of  pregnancy,  a  strange  series  of  phenomena  occur ; 


ABNORMAL    PREGNANCY.  179 

pseudo-labor  comes  on,  there  are  more  or  less  frequent  and  strong 
uterine  contractions,  possibly  an  escape  of  blood  from  the  vagina,  the 
discharge  of  the  broken  down  uterine  decidua,  and  even  the  estab- 
lishment of  lactation.     Sometimes  the  contractions  of  the  abdominal 


Uleius  iiud  Foetus  ia  a  Case  of  Abdominal  Preguancy. 

muscles,  produced  bj  this  ineffective  labor,  have  been  so  strong  as  to 
cause  the  laceration  of  the  adventitious  cyst  surrounding  the  foetus. 
and  the  escape  of  blood  and  liquor  amnii  into  the  abdominal  cavity, 
with  a  rapidly  fatal  result.  More  frequently  laceration  does  not 
occur,  and  the  spurious  labor  pains  continue  at  intervals,  until  the 
foetus  dies,  possibly  from  pressure,  but  more  often  from  effusion  of 
blood  into  the  tissue  of  the  placenta,  and  consequent  asphyxia.  Occa- 
sionally the  foetus  has  apparently  lived  a  considerable  time,  in  some 
cases  even  for  several  months,  after  the  natural  limit  of  pregnancy 
has  been  reached. 

Changes  after  the  Death  of  the  Fcetus. — It  is  after  the  death  of  the 
foetus  that  the  dangers  of  abdominal  pregnancy  generally  commence, 
and  they  are  numerous  and  various.  The  subsequent  changes  that 
occur  are  well  worthy  of  study.  Occasionally  the  foetus  has  been 
retained  for  a  length  of  time,  even  until  the  end  of  a  long  life,  with- 
out producing  any  serious  discomfort,  and  in  many  cases  of  this  kind 
several  normal  pregnancies  and  deliveries  have  subsequently  taken 
place.  Even  when  the  extra- uterine  gestation  appears  to  be  tolerated, 
and  has  remained  for  long  without  producing  any  bad  effects,  serious 
symptoms  may  be  suddenly  developed ;  so  that  no  woman,  under 
such  circumstances,  can  be  considered  safe.  The  condition  of  these 
retained  foetuses  varies  much.  Most  commonly  the  liquor  amnii  is 
absorbed,  the  foetus  shrinks  and  dies,  all  its  soft  structures  are  changed 
into  adipocere,  and  the  bones  only  remain  unaltered.  Sometimes 
this  change  occurs  with  great  rapidity.     I  have  elsewhere^  recorded 

'  Obst.  Trans,  vii. 


180 


PREGNANCY. 


a  case  of  extra-uterine  foetation  in  which  at  the  full  term  of  pregnancy 
the  foetus  was  alive,  and  the  woman  died  in  less  than  a  year  after- 
wards. On  post-mortem  the  foetus  was  found  entirely  transformed 
into  a  greasy  mass  of  adipocere,  studded  with  foetal  bones,  in  which 
not  a  trace  of  any  of  the  soft  parts  could  be  detected.  On  the  other 
hand  the  foetus  may  remain  unchanged  ;  in  the  Museum  of  the 
College  of  Surgeons  there  is  one  which  was  retained  in  the  abdomen 
for  fifty-two  years,  and  which  was  found  to  be  as  fresh  and  unaltered 
as  a  new-born  child.     In  other  cases  the  sac  and  its  contents  atrophy 

and  shrink,  and  calcareous  matter  is  de- 
posited in  them,  so  that  the  whole  be- 
comes converted  into  a  solid  mass  known 
as  a  lithopsedion  (Fig.  81).  -The  cases, 
however,  in  which  the  retention  of  the 
foetus  gives  rise  to  no  mischief  are  quite 
exceptional.  Generally  the  foetus  putre- 
fies, and  this  may  either  immediately 
cause  fatal  peritonitis  or  septicaemia  ;  or, 
as  more  commonly  happens,  secondary 
inflammation  and  suppuration  of  the  sac. 
Under  the  influence  of  the  latter  the  sac 
opens  externally,  either  directly  at  some 
point  of  the  abdominal  walls,  or  indi- 
rectly through  the  vagina,  the  bowels, 
or  even  the  bladder.  Through  the  aper- 
ture or  apertures  thus  formed  (for  there 
are  often  several  fistulous  openings),  pus, 
and  the  bones  and  other  parts  of  the 
broken-down  foetus,  are  discharged  ;  and 
this  may  go  on  for  months,  and  even 
years,  until  at  last,  if  the  patient's  strength,  does  not  give  way,  the 
whole  contents  of  the  cyst  are  expelled,  and  recovery  takes  place. 
From  various  statistical  observations  it  appears,  that  the  chances  of 
recovery  are  best  when  the  cyst  opens  through  the  abdominal  walls, 
next  through  the  vagina  or  bladder,  and  that  the  foetus  is  discharged 
with  most  difficulty  and  danger  when  the  aperture  is  formed  into 
the  bowel.  At  the  best,  however,  the  process  is  long,  tedious,  and 
full  of  dangers ;  and  the  patient  too  often  sinks,  during  the  attempt 
at  expulsion,  through  the  irritation  and  exhaustion  produced  by  the 
abundant  and  long-continued  discharge. 

Diagnosis. — The  diagnosis  of  abdominal  gestation  is  by  no  means 
so  easy  as  might  be  thought,  and  the  most  experienced  practitioners 
have  been  mistaken  with  regard  to  it. 

The  most  characteristic  symptom,  although  this  is  not  so  common 
as  in  tubal  gestation,  is  metrorrhagia  combined  with  the  general 
signs  of  pregnancy.  Very  severe  and  frequently  repeated  attacks 
of  abdominal  pain  are  rarely  absent,  and  should  at  once  cause  sus- 
picion, especially  if  associated  with  hemorrhage.  They  are  supposed 
by  some  to  depend  on  intercurrent  attacks  of  peritonitis,  by  which 
the  foetal  cyst  is  formed.     Parry  doubts  this  explanation,  and  attrib- 


Lithopsedion. 

(From  a  preparation  in  the  Museum  of 
the  College  of  Surgeous  j 


ABNOllMAL    PREGNANCY.  181 

utes  them  partly  to  tlie  distension  of  the  cyst  by  the  growing  fcjetus, 
and  partly  to  pressure  on  the  surrounding  structures.  On  palpation 
the  form  of  the  abdomen  will  be  observed  to  differ  from  that  of  nor- 
mal pregnancy,  being  generally  more  developed  in  the  transverse 
direction,  and  the  rounded  outline  of  the  gravid  uterus  cannot  be 
detected.  When  development  has  advanced  nearly  to  term,  the  ex- 
treme distinctness  with  which  the  foetal  limbs  can  be  felt  will  arouse 
suspicion.  Per  vaginam  the  os  and  cervix  will  be  felt  softened  as  in 
ordinary  pregnancy,  but  often  displaced  by  the  pressure  of  the  cyst, 
and  sometimes  fixed  by  peri-metritic  adhesions  ;  either  of  these  signs 
is  of  great  diagnostic  value. 

By  bimanual  examination  it  may  be  possible  to  make  out  that  the 
uterus  is  not  greatly  enlarged,  and  that  it  is  distinctly  separate  from 
the  bulk  of  the  tumor;  these  facts,  if  recognized,  would  of  them- 
selves disprove  the  existence  of  uterine  gestation.  The  diagnosis,  if 
the  foetal  limbs  or  heart-sounds  could  be  detected,  would  be  cleared 
up  in  any  case  by  the  uterine  sound,  which  would  show  that  the 
uterus  was  empty  and  only  slightly  elongated.  But  we  must  be  care- 
ful not  to  resort  to  this  test  unless  the  existence  of  uterine  gestation 
is  positively  disproved  by  other  means.  As,  however,  it  places  the 
diagnosis  beyond  a  doubt,  it  should  always  be  employed  whenever 
operative  procedure  is  in  contemplation.  Quite  recently  I  have  seen 
a  remarkable  case  which  illustrates  the  importance  of  this  rule.  The 
case  had  been  diagnosed  as  abdominal  pregnancy  by  no  less  than  six 
experienced  practitioners,  and  was  actually  on  the  operating  table  for 
the  performance  of  laparotomy.  As  a  precaution,  having  some  doubts 
of  the  diagnosis,  I  suggested  the  passage  of  the  sound,  which  entered 
into  a  gravid  uterus,  the  case  proving  to  be  one  of  small  ovarian 
tumor  jammed  down  into  Douglas's  space,  and  displacing  the  cervix 
forwards.  Had  it  not  been  for  this  precaution  its  true  nature  would 
ceriainly  not  have  been  detected. 

Treatment. — The  treatment  of  abdominal  gestation  will  always  be 
a  subject  of  anxious  consideration,  and  there  is  much  difference  of 
opinion  as  to  the  proper  course  to  pursue.  It  is  pretty  generally 
admitted  that  it  is  not  advisable  to  adopt  any  active  measures  until 
the  full  term  of  development  is  reached.  Puncturing  the  cyst,  with 
the  view  of  destroying  the  foetus  and  arresting  its  further"^  growth, 
has  been  practised,  but  there  are  good  grounds  for  rejecting  it,  for 
there  is  not  the  same  imminent  risk  of  death  from  rupture  of  the 
cyst  as  in  tubal  foetation ;  and  even  if  the  destruction  of  the  fo3tus 
could  be  brought  about,  there  would  still  be  formidable  dangers  from 
subsequent  attempts  at  elimination,  or  from  internal  hemorrhage. 

Primary  Gastrotomy. — When  the  full  period  has  arrived,  the  child 
being  still  alive,  as  proved  by  auscultation,  we  have  to  consider 
whether  it  may  not  be  advisable  to  perform  gastrotomy  before  the 
foetus  perishes,  and  so  at  least  save  the  life  of  the  child.  There  are 
few  questions  of  greater  importance,  and  more  difficult  to  settle.  The 
tendency  of  medical  opinion  is  rather  in  favor  of  immediate  opera- 
tion, which  is  recommended  by  Velpeau,  Kiwisch,  Koeberle,  Schroe- 
der,  and  many  other  writers,  whose  opinion  necessarily  carries  great 


182  PREGNANCY. 

weight.  The  arguments  used  in  favor  of  immediate  operations  are 
that,  while  it  affords  a  probability  of  saving  the  child,  the  risks  to 
the  mother,  great  though  they  undoubtedly  are,  are  not  greater  than 
those  which  maybe  anticipated  by  delay.  If  we  put  off  interference 
the  cyst  may  rupture  during  the  ineffectual  efforts  at  labor,  and  death 
at  once  ensue  ;  or,  if  this  does  not  take  place,  other  risks,  which  can 
never  be  foreseen,  are  always  in  store  for  the  patient.  She  may  sink 
from  peritonitis,  or  from  exhaustion,  consequent  on  the  efforts  at 
elimination,  which  in  the  majority  of  cases  are  sooner  or  later  set  up, 
so  that,  as  Barnes  properly  sa3^s,  "  the  patient's  life  may  be  said  to 
be  at  the  mercy  of  accidents,  of  which  we  have  no  sufficient  warn- 
ing." On  the  other  hand,  if  we  delay,  while  we  sacrifice  all  hope  of 
saving  the  child,  we  at  least  give  the  mother  the  chance  of  the  foeta- 
tion  remaining  quiescent  for  a  length  of  time,  as  certainly  not  infre- 
quently occurs.  Thus,  Campbell  collected  62  cases  of  ultimate  re- 
covery after  abdominal  gestation,  in  21  of  which  the  foetus  was 
retained  without  injury  for  a  number  of  years.  Then  there  is  the 
question  of  secondary  gastrotomy,  which  consists  in  operating  after 
the  death  of  the  foetus  when  urgent  symptoms  have  arisen,  a  course 
which  is  advocated  by  Mr.  Hutchinson.  In  favor  of  this  procedure 
it  is  urged,  that  by  delay  the  inflammation  taking  place  about  the 
cyst  will  have  greatly  increased  the  chance  of  adhesions  having 
formed  between  it  and  the  abdominal  parietes,  so  as  to  shut  off'  its 
contents  from  the  cavity  of  the  peritoneum.  The  more  effectually 
this  has  been  accomplished,  the  greater  are  the  patient's  chances  of 
recovery.  "When  the  foetus  has  been  dead  for  some  time  the  vascu- 
larity of  the  cyst  will  also  be  lessened,  and  the  placental  circulation 
will  have  ceased,  so  that  the  danger  of  hemorrhage  will  be  much 
diminished. 

It  will  be  seen,  therefore,  that  there  are  arguments  in  favor  of 
each  of  these  views.  The  results  of  the  primary  operation  are  far 
less  favorable  than  we  should  have,  a  priori,  supposed.  Since  the 
first  edition  of  this  work  appeared  the  subject  has  been  carefully 
studied  by  Dr.  Parry  in  his  exhaustive  treatise  on  Extra-Uterine 
Foetation.  He  has  there  shown  that  when  the  case  is  left  until 
nature  has  shown  the  channel  through  which  elimination  is  to  be 
effected,  the  mortality  is  17.35  less  than  in  the  cases  in  which  the 
primary  operation  was  performed.  His  conclusion  is,  that  "the  pri- 
mary operation  cannot  be  too  forcibly  condemned.  It  is  not  too  much 
to  say  that  this  operation  adds  only  another  danger  to  a  life  already 
trembling  in  the  balance,  which  the  delusive  hope  of  saving  the  un- 
certain life  of  a  child  does  not  warrant  us  in  assuming."  It  is  only 
just  to  remember,  as  is  forcibly  pointed  out  by  Keller,  that  in  these 
days  of  advanced  abdominal  surgery  a  better  result  might  be  antici- 
pated than  when  gastrotomy  was  performed  in  the  haphazard  way 
which  was  usual  before  we  had  gained  experience  from  ovariotomy. 
No  doubt  minute  care  in  the  performance  of  the  operation,  a  due 
attention  to  its  details,  studiously  avoiding,  as  much  as  possible,  the 
passage  of  blood  and  the  contents  of  the  cyst  into  the  peritoneal 
cavity,  and  a  free  use  of  antiseptics  would  materially  lessen  its  peril. 


ABNORMAL    PREGNANCY.  183 

This  conclusion  is  well  illustrated  in  a  recent  interesting  paper  by 
Thomas,  who  relates  three  successful  cases  of  laparotomy  in  aVjdomi- 
nal  pregnancy.' 

Mode  of  'performiwj  the  O'peration. — The  operation,  then,  should  be 
performed  with  all  the  precaution  with  which  we  surround  ovari- 
otomy.    The   incision,  best   made  in  the  linea  alba,  should  not  be 
greater  than  is  necessary  to  extract  the  foetus,  and  may  be  lengthened 
as  occasion  requires.     It  has  been  suggested  that  should  the  head 
be  felt   presenting   above    the   vagina,   the   intervening   structures 
should  be  divided,  and  the  foetus  withdrawn  by  the  forceps.     This 
procedure  was  actually  adopted  with  success  in  1816,  by  Dr.  John 
King,  of  Edisto  Island,  South  Carolina.    If  there  are  no  adhesions  the 
walls  of  the  cyst  should  be  stitched  to  the  margin  of  the  incision,  so 
as  to  shut  it  off' as  completely  as  possible  from  the  peritoneal  cavity. 
This  has  been  specially  insisted  on  by  Braxton  Ilicks,  and  should 
never  be  omitted.     The  special  risk  is  not  so  much  the  Avounding  of 
the  peritoneum,  as  the  subsequent  entrance  of  septic  matter  from  the 
cyst  into  its  cavity.     Another   cardinal  rule,  both  in  primary  and 
secondary  gastrotomy,  is  to  make  no  attempt  to  remove  the  placenta. 
Its  attachments  are  generally  so  deep  seated  and  diffused,  that  any 
endeavor  to  separate  it  is  likely  to  be  attended  with  profuse  and  un- 
controllable hemorrhage,  or  with   serious  injury  to  the  structure  to 
which  it  is  attached.     Many  of  the  failures  after  operating  can  be 
traced  to  a  neglect  of  this  rule.     The  best  subsequent  course  to  pur- 
sue, after  removing  the  foetus  and  arresting  all  hemorrhage,  either 
by  ligature  or  the  actual  cautery,  is  to  sponge  out  the  cyst  as  gently 
as  possible,  and  then  to  bring  the  upper  part  of  the  wound  into  appo- 
sition with  sutures,  leaving  the  lower  open,  with  the  cord  protruding 
so  as  to  insure  an  outlet  for  the  escape  of  the  placenta  as  it  slips 
down.    The  subsequent  treatment  must  be  specially  directed  to  favor 
the  escape  of  the  discharge,  and  to  prevent  the  risk  of  septicaemia. 
These  objects  may  be  much  aided  by  injections  of  antiseptic  fluids, 
such  as  a  solution  of  carbolic  acid,  or  diluted  Condy's  fluid;  and  it 
would  perhaps  be  advisable   to  place  a  drainage  tube  in  the  lower 
angle  of  the  wound.     It  may  be  well  to  point  out  that  there  is  no 
operation  in  which  a  scrupulous  following  of  the  antiseptic  method, 
on  Mr.  Lister's  principles,  is  so  likely  to  be  useful. 

Treatment  when  the  Foetus  is  Dead. — -As  long  as  the  placenta  is  re- 
tained the  danger  is  necessarily  great,  and  it  may  be  many  days  or 
even  weeks  before  it  is  discharged.  When  once  this  is  aff'ected  the 
sac  may  be  expected  to  contract,  and  eventually  to  close  entirely. 

When  the  foetus  is  dead,  or  when  we  have  determined  not  to  attempt 
primary  gastrotomy,  it  is  advisable  to  wait,  very  carefully  watching 
the  patient,  until  either  the  gravity  of  her  general  symptoms,  or  some 
positive  indication  of  the  channel  through  which  nature  is  about  to 
attempt  to  eliminate  the  foetus,  shows  us  that  the  time  for  action  has 
arrived.  If  there  be  distinct  bulging  of  the  cyst  in  the  vagina,  or  in 
the  retro-vaginal  cul-de-sac,  especially  if  an  opening  has  formed  there, 

I  Am.  Journ.  of  Med.  Sci.,  Jan.  1879. 


184  PREGJSJANUY. 

we  may  properly  content  ourselves  with  aiding  the  passage  of  the 
foetus  through  the  channel  thus  indicated,  and  removing  the  parts 
that  present  piecemeal  as  they  come  within  reach,  cautiously  enlarg- 
ing the  aperture  if  necessary.  If  the  sac  have  opened  into  the  intes- 
tines, the  expulsion  of  the  foetus  through  this  channel  is  so  tedious 
and  difficult,  the  exhaustion  attending  it  so  likely  to  prove  fatal,  and 
the  danger  from  decomposition  of  the  foetus  through  passage  of  in- 
testinal gas  so  great,  that  it  would  probably  be  best  to  attempt  to 
remove  it  by  gastrotomy,  especially  if  it  is  only  recently  dead,  and 
the  greater  portion  is  still  retained. 

Mode  of  Performing  Secondary  Gastrotomy. — If  an  opening  forms 
at  the  abdominal  parietes,  or  if  the  symptoms  determine  us  to  resort 
to  secondary  gastrotomy  before  this  occurs,  the  operation  must  be 
performed  in  the  same  way,  and  with  the  same  precautions,  as  primary 
gastrotomy.  Here,  as  before,  the  safety  of  the  operation  must  greatly 
depend  on  the  amount  and  firmness  of  the  adhesions  ;  for  if  the  cyst 
be  not  completely  shut  off'  from  the  peritoneal  cavity,  the  risks  of  the 
operation  will  be  little  less  than  those  of  primarj^  gastrotomy.  It 
would  obviously  materially  influence  our  decision  and  prognosis  if 
we  could  determine  this  point  before  operating.  Unfortunately  it  is 
impossible,  as  the  experience  of  ovariotomists  proves,  to  ascertain 
the  existence  of  adhesions  with  any  certainty.  If,  however,  we  find 
that  the  abdominal  parietes  do  not  move  freely  over  the  cyst,  and  if 
the  umbilicus  be  depressed  and  immovable,  the  presumption  is  that 
considerable  adhesions  exist.  If  they  are  found  not  to  be  present, 
the  cyst  walls  should  be  stitched  to  the  margin  of  the  incision,  in  the 
manner  already  indicated,  before  the  contents  are  removed. 

If  the  foetus  has  been  long  dead,  and  its  tissues  greatly  altered,  its 
removal  may  be  a  matter  of  difficulty.  In  the  case  under  my  own- 
care,  already  alluded  to,  the  foetal  structures  formed  a  sticky  mass 
of  such  a  nature,  that  I  believe  it  would  have  been  impossible  to 
empty  the  cyst  had  an  operation  been  attempted.  This  possibility 
would  be,  to  some  extent,  a  further  argument  in  favor  of  the  primaj:"y 
operation. 

Opeiiing  of  Cyst  Inj  Caustics. — The  importance  of  adhesion  has  led 
some  practitioners  to  recommend  the  opening  of  the  cyst  by  potassa 
fusa  or  some  other  caustic,  in  the  hope  that  it  would  set  up  adhesive 
inflammation  around  the  apertures  thus  formed.  Several  successful 
operations  by  this  method  are  recorded,  and  it  would  be  worth 
trying,  should  the  extreme  mobility  of  the  cyst  lead  us  to  suspect 
that  no  adhesions  existed.  If  we  have  to  deal  with  a  case  in  which 
fistulous  openings  leading  to  the  cyst  have  already  formed,  it  may, 
perhaps,  be  advisable  to  dilate  the  apertures  already  existing,  rather 
than  make  a  fresh  incision  ;  but,  in  determining  this  point,  the  sur- 
geon will  natiirally  be  guided  by  the  nature  of  the  case,  and  the 
character  and  direction  of  the  fistulous  openings. 

General  Treatment. — It  is  almost  needless  to  say  anything  of 
general  treatment  in  these  trying  cases ;  but  the  administration  of 
opiates  to  allay  the  sufferings  of  the  patient,  and  the  endeavor  to 


ABNORMAL    PREGNANCY.  185 

support  the  severely  taxed  vital  energies  by  appropriate  food  and 
medication,  will  form  a  most  important  part  of  the  management. 

Gestation  in  a  Bi-lohed  Uterus. — A  few  words  may  be  said  as  to 
gestation  in  the  rudimentary  horn  of  a  bi-lobed  uterus,  to  which 
considerable  attention  has  of  late  years  been  directed  by  the  writings 
of  Kussmaul  and  others.  It  appears  certain  that  many  cases  of 
supposed  tubal  gestation  are  really  to  be  referred  to  this  category. 
Although  such  cases  are  of  interest  pathologically,  they  scarcely  re- 
quire much  discussion  from  a  practical  point  of  view,  inasmuch  as 
their  history  is  pretty  nearly  identical  with  that  of  tubal  pregnancy. 
The  rudimentary  horn  is  distended  by  the  enlarging  ovum,  and  after 
a  time,  when  further  distension  is  impossible,  laceration  takes  place. 
As  a  matter  of  fact,  all  the  13  cases  collected  by  Kussmaul  termi- 
nated in  this  way;  and  even  on  post-mortem  examination  it  is  often 
extremely  difficult  to  distinguish  them  from  tubal  pregnancies.  The 
best  way  of  doing  is  probably  by  observing  the  relations  of  the 
round  ligaments  to  the  tumor,  for,  if  the  gestation  be  tubal,  thev  will 
be  found  attached  to  the  uterus  on  the  inner  or  uterine  side  of  the 
cyst;  whereas,  if  the  pregnancy  be  in  a  rudimentary  horn  of  the 
uterus,  they  will  be  pushed  outwards  and  be  external  to  the  sac.  In 
the  latter  case,  moreover,  the  sac  will  be  probably  found  to  contain 
a  true  decidua,  which  is  not  the  case  in  tubal  pregnanc3^  The  only 
point  in  which  they  differ  is  that  in  cornual  pregnancy  rupture  may 
be  delayed  to  a  somewhat  later  period  than  in  tubal,  on  account  of 
the  greater  distensibility  of  the  supplementary  horn. 

Missed  Labor. — The  term  "  missed  lahor''^  is  applied  to  an  exceed- 
ingly rare  class  of  cases  in  which,  at  the  full  period  of  pregnanc3%  labor 
has  either  not  come  on  at  all,  or,  having  commenced,  the  pains  have 
subsequently  passed  off,  and  the  foetus  is  retained  in  ufcero  for  a  very 
considerable  length  of  time.  Under  such  circumstances  it  has  usually 
happened  that  the  membranes  have  ruptured  at  or  about  the  proper 
term,  and  the  access  of  air  to  the  foetus  in  utero  has  been  followed 
by  decomposition.  A  putrid  and  offensive  discharge  has  then  com- 
menced, and  eventually  portions  of  the  disintegrating  foetus  have 
been  expelled  per  vaginain.  This  discharge  may  go  on  until  the  en- 
tire foetus  is  gradually  thrown  off;  or,  more  frequently,  the  patient 
dies  from  septicaemia,  or  other  secondary  result  of  the  presence  of  the 
decomposing  mass  in  utero. 

Thus  McClintock  relates  one  case,^  in  which  symptoms  of  labor 
came  on  in  a  woman,  15  years  of  age,  at  the  expected  period  of  de- 
livery, but  passed  off  without  the  expulsion  of  the  foetus.  For  a 
period  of  sixty-seven  weeks  a  highly  offensive  discharge  came  away, 
with  some  few  bones,  and  she  eventually  died  with  symptoms  of 
pyaemia.  He  also  cites  another  case  in  which  the  patient  died  in  the 
same  way,  after  the  foetus  had  been  retained  for  eleven  years. 

[Two  very  remarkable  cases  have  occurred  in  the  United  States, 
which  are  especially  worthy  of  note  as  the  women  became  the  sub- 
jects of  the  Caesarean  section.     The  first^  occurred  in  a  mulatto  of  25, 

'  Dublin  Quart.  Journ.,  Feb.  and  May,  1864. 
-JO  [^  Am,  Jour.  Med.  Sci.  vol.  xviii.  page  257.] 


186 


PREGNANCY, 


the  motlier  of  three  or  four  children,  a  native  of  Virginia,  who  car- 
ried her  foetus  two  years,  and  was  in  labor  at  intervals  during  fifteen 
months.  She  was  affected  with  occlusion  of  the  cervix,  and  had  a 
calcareous  incrustation  over  and  around  the  internal  os.  Gastro-hys- 
terotomy  was  performed  in  1828  and  a  putrid  foetus  removed.  The 
woman  was  doing  well  until  the  middle  of  the  second  week  when  she 
was  seized  with  peritonitis  after  a  meal  of  meat  and  cider. 

The  second^  woman  was  black,  set.  33  ;  mother  of  one  child  ;  car- 
ried her  foetus  three  and  a  half  years ;  had  a  partial  rupture  of  the 
uterus  at  four  months  and  nearly  died  ;  was  in  labor  at  term,  but 
foetus  did  not  descend ;  pains  at  intervals  for  a  month ;  an  abscess 
opened  near  umbilicus  in  about  twenty  months  ;  Ca3sarean  section  in 
1860,  in  Louisiana;  abdominal  cavity  not  opened;  foetus  putrid; 
one  foot  and  hand  found  secured  by  bands  in  a  pouch  on  the  left  side 
of  the  uterus  ;  woman  recovered.  She  had  been  attended  in  her  labor 
by  a  midwife. — Ed.] 

Ulceration  of  the  Uterine  Walls. — Sometimes,  when  the  foetus  has 
been  retained  for  a  length  of  time,  a  further  source  of  danger  has 


Fig.  82. 


Contents  of  the  Cyst  in  Dr.  Oldham's  case  of  Missed  Labor. 

been  added  by  ulceration  or  destruction  of  the  uterine  walls,  proba- 
bly in  consequence  of  an  ineffectual  attempt  at  its  elimination.  This 
occurred  in  Dr.  Oldham's  case  (Fig.  82),  in  which  the  contained  mass 
is  said  to  have  nearly  worn  through  the  anterior  wall  of  the  uterus ; 

[1  N.  0.  Med.  and  Surg.  Jour.,  July,  1877,  p.  35.] 


ABNORMAL    PREGNANCY.  187 

and  also  in  one  reported  by  Sir  James  Simpson/  in  which  a  patient 
died  three  months  after  term,  the  ftxitus  having  undergone  fatty  meta- 
morphosis, an  opening  the  size  of  half-a-crown  having  formed  between 
the  transverse  colon  and  tlie  uterine  cavity.  It  is  also  stated  that 
"  the  uterine  walls  were  as  thin  as  parchment." 

In  some  few  cases,  however,  probably  when  the  entrance  of  air 
has  been  prevented,  the  foetus  has  been  retained  for  a  length  of  time 
without  decomposing,  and  without  giving  rise  to  any  troublesome 
symptoms.  Such  a  case  is  reported  by  Dr.  Cheston,^  in  which  the 
foetus  remained  in  utero  for  fifty-two  years. 

Its  Causes. — The  causes  of  this  strange  occurrence  are  altogether 
unknown.  Generally  the  foetus  seems  to  have  died  some  time  before 
the  proper  term  for  labor,  and  this  may  have  influenced  the  character 
of  the  pains.  It  is  probably  also  most  apt  to  occur  in  women  of 
feeble  and  inert  habit  of  body,  possibly  where  there  was  some  obsta- 
cle to  the  dilatation  of  the  cervix,  which  the  pains  were  unable  to 
overcome.  Barnes  suggests^  that  some  presumed  examples  of  missed 
labor  "  Avere  really  cases  of  interstitial  gestation,  or  gestation  in  one 
horn  of  a  two-horned  uterus."  In  several  of  the  cases,  however,  the 
details  of  the  post-mortem  examination  are  too  minute  to  admit  of 
the  possibility  of  mistake  having  been  made. 

Miiller,  of  Nancy,  has  recently  attempted  to  prove,  by  a  critical 
examination  of  published  cases,  that  most  examples  of  so-called 
"  mixed  labor"  were  in  reality  cases  of  extra-uterine  foetation,  in 
which  an  ineffectual  attempt  at  parturition  took  place,  the  foetus 
being  subsequently  retained. 

From  what  has  been  said,  it  will  be  seen  that  the  dangers  arising 
from  this  state  are  very  considerable,  and  when  once  the  full  term 
has  passed  beyond  doubt,  especially  if  the  presence  of  an  offensive 
discharge  shows  that  deconiDosition  of  the  foetus  has  commenced,  it 
would  be  proper  practice  to  empty  the  uterus  as  soon  as  possible. 
The  necessary  precaution,  however,  is  not  to  decide  too  quickly  that 
the  term  has  really  passed  ;  and,  therefore,  we  must  either  allow 
sufficient  time  to  elapse  to  make  it  quite  certain  that  the  case  really 
falls  under  this  category,  or  have  unequivocal  signs  of  the  death  of 
the  foetus,  and  injury  to  the  mother's  health.  If  we  had  to  deal  with 
the  case  before  any  extensive  decomposition  of  the  foetus  had  occur- 
red, we  probably  should  find  little  difficulty  in  its  management,  for 
the  proper  course  then  would  be  to  dilate  the  cervix  with  the  fluid 
dilators,  and  remove  the  foetus  by  turning;  or,  before  doing  so,  we 
might  endeavor  to  excite  uterine  action  by  pressure  and  ergot.  If 
the  case  did  not  come  under  observation  until  disintegration  of  the 
foetus  had  begun,  it  would  be  more  difficult  to  deal  with.  If  the 
foetus  had  become  so  much  broken  up  that  it  was  being  discharged 
in  pieces,  Dr.  McClintock  says  that  "  in  regard  to  treatment,  our 
measures  should  consist  mainly  of  palliatives,  viz.,  rest  and  hip-l3aths 
to  subdue  uterine  irritation;   vaginal  injections  to  secure  cleanliness 

»  Edin.  Med.  Journ.,  1865.  z  Med.  Chir.  Trans.,  1814. 

3  Diseases  of  Women,  p.  445. 


188  PREGNANCY. 

and  prevent  excoriation  ;  occasional  digital  examination,  so  as  to  de- 
tect any  fragments  of  bone  that  might  be  presenting  at  the  os,  and  to 
assist  in  removing  them.  These  are  plain  rational  measures,  and 
beyond  them  we  shall  scarcely,  perhaps,  be  justified  in  venturing. 
Nevertheless,  under  certain  circumstances,  I  would  not  hesitate  to 
dilate  the  cervical  canal  so  as  to  permit  of  examining  the  interior  of 
the  womb,  and  of  extractiug  any  fragments  of  bone  that  may  be 
easily  accessible  ;  but  unless  they  could  thus  be  easily  reached  and 
removed,  the  safer  course  would  be  to  defer,  for  the  present,  interfer- 
ing with  them.^ 

It  may  be  doubted,  I  think,  whether,  considering  the  serious 
results  which  are  known  to  have  followed  so  many  cases,  it  would 
not,  on  the  whole,  be  safer  to  make  at  least  one  decided  effort,  under 
chloroform,  to  remove  as  much  as  possible  of  the  putrefying  uterine 
contents,  after  the  os  has  Vjeen  fully  dilated.  Such  a  procedure  would 
be  less  irritating  than  frequently  repeated  endeavors  to  pick  away 
detached  portions  of  the  foetus,  as  they  present  at  the  os  uteri. 
When  once  the  os  is  dilated,  antiseptic  intra-uterine  injections,  as 
of  diluted  Condy's  fluid,  might  safely  and  advantageously  be  used. 
Unquestionably,  it  would  be  better  practice  to  interfere  and  emptv 
the  uterus  as  soon  as  we  are  quite  satisfied  of  the  nature  of  the  case, 
rather  than  to  delay,  until  the  foetus  has  been  disintegrated. 


CHAPTEE  yil. 

DISEASES  OF  PEEGNANCY. 

The  diseases  of  pregnancy  form  a  subject  so  extensive  that  they 
might  well  of  themselves  furnish  ample  material  for  a  separate 
treatise.  The  pregnant  woman  is,  of  course,  liable  to  the  same 
diseases  as  the  non-pregnant ;  but  it  is  only  necessary  to  allude  to 
those  whose  course  and  effects  are  essentially  modified  by  the  exist- 
ence of  pregnancy,  which  have  some  peculiar  effect  on  the  patient 
in  consequence  of  her  condition.  There  are,  moreover,  many  dis- 
orders which  can  be  distinctly  traced  to  the  existence  of  pregnancy. 
Some  of  them  are  the  direct  results  of  the  sympathetic  irritations 
which  are  then  so  commonly  observed  ;  and,  of  these,  several  are 
only  exaggerations  of  irritations  which  may  be  said  to  be  normal 
accompaniments  of  gestation.  These  functional  derangements  may 
be  classed  under  the  head  of  neuroses,  and  they  are  sometimes  so 
slight  as  merely  to  cause  temporary  inconvenience,  at  others  so  grave 
as  seriously  to  imperil  the  life  of  the  patient.      Another  class  of 

1  Dublin  Quart.  Joiirn.,  vol.  sxxvii.  p.  314. 


DIHEASES    OF    PREGNANCY.  189 

disorders  are  to  be  traced  to  local  causes  in  connection  with  the  gravid 
uterus,  and  are  eitlier  the  mechanical  results  of  pressure,  or  of  some 
displacement,  or  morbid  state  of  the  uterus;  while  the  origin  of 
others  may  be  said  to  be  complex,  being  partly  due  to  sympathetic 
irritation,  partly  to  pressure,  and  partly  to  obscure  nutritive  changes 
produced  by  the  pregnant  state. 

Deranyeraerds  of  the  Digestive  System. — Among  the  sympathetic 
derangements  there  are  none  which  are  more  common,  and  none 
which  more  frequently  produce  distress,  and  even  danger,  than  those 
which  affect  the  digestive  system.  Under  the  heading  of  ''The  Signs 
of  Pregnancy,"  the  frequent  occurrence  of  nausea  and  vomiting  has 
already  been  discussed,  and  its  most  probable  causes  considered  (p. 
137).  A  certain  amount  of  nausea  is,  indeed,  so  common  an  accom- 
paniment of  pregnancy,  that  its  consideration  as  one  of  the  normal 
symptoms  of  that  state  is  fully  justified.  We  need  here  only  discuss 
those  cases  in  which  the  nausea  is  excessive  and  long-continued,  and 
leads  to  serions  results  from  inanition,  and  from  the  constant  distress 
it  occasions.  Fortunately  a  pregnant  woman  may  bear  a  surprising 
amount  of  nausea  and  sickness  without  constitutional  injury,  so  that 
apparently  almost  all  aliments  may  be  rejected,  witJiout  the  nutrition 
of  the  body  very  materially  suffering.  At  times  the  vomiting  is 
limited  to  the  early  part  of  the  day,  when  all  food  is  rejected,  and 
when  there  is  a  frequent  retching  of  glairy  transparent  fluid,  in 
severe  cases  mixed  with  bile,  while  at  the  latter  part  of  the  day  the 
stomach  may  be  able  to  retain  a  sufficient  quantity  of  food,  and  the 
nausea  disappears.  In  other  cases  the  nausea  and  vomiting  are 
almost  incessant.  The  patient  feels  constantly  sick,  and  the  mere 
taste  or  sight  of  food  may  bring  on  excessive  and  painful  vomiting. 
The  duration  of  this  distressing  accompaniment  of  pregnancy  is  also 
variable.  Generally  it  commences  between  the  second  and  third 
months,  and  disappears  after  the  woman  has  quickened.  Sometimes, 
however,  it  begins  with  conceptioi^,  and  continues  unabated  until 
the  pregnancy  is  over. 

Sym.ptoms  of  the  Graver  Cases. — In  the  worst  class  of  cases,  when 
all  nourishment  is  rejected,  and  when  the  retching  is  continuous  and 
painful,  symptoms  of  very  great  gravity,  which  may  even  prove 
fatal,  develop  themselves.  The  countenance  becomes  haggard  from 
suffering,  the  tongue  dry  and  coated,  the  epigastrium  tender  on  pres- 
sure, and  a  state  of  extreme  nervous  irritability,  attended  with  rest- 
lessness and  loss  of  sleep,  becomes  established.  In  a  still  more  aggra- 
vated degree,  there  is  general  feverishness,  with  a  rapid,  small,  and 
thready  pulse.  Extreme  emaciation  supervenes,  the  result  of  wast- 
ing from  lack  of  nourishment.  The  breath  is  intensely  fetid,  and 
the  tongue  dry  and  black.  The  vomited  matters  are  sometimes 
mixed  with  blood.  The  patient  becomes  profoundly  exhausted,  a 
low  form  of  delirium  ensues,  and  death  may  follow  if  relief  is  not 
obtained. 

Prognosis. — Symptoms  of  such  gravity  are  fortunately  of  extreme 
rarity,  but  they  do  from  time  to  time  arise,  and  cause  much  anxiety. 
Gueniot  collected  118  cases  of  this  form  of  the  disease,  out  of  which 


190  PREGNANCY. 

46  died;  and  out  of  the, 72  that  recovered,  in  42  the  symptoms  only 
ceased  when  abortion,  either  spontaneous,  or  artificially  produced, 
had  occurred.  When  pregnancy  is  over  the  symptoms  occasionally 
cease  with  marvellous  rapidity.  The  power  of  retaining  and  assimi- 
lating food  is  rapidly  regained,  and  all  the  threatening  symptoms 
disappear. 

Treatment. — In  the  milder  forms  of  obstinate  vomiting,  one  of  the 
first  indications  will  be  to  remedy  any  morbid  state  of  the  primse 
via?.  The  bowels  will  not  infrequently  be  found  to  be  obstinately 
constipated,  the  tongue  loaded,  and  the  breath  oftensive ;  and  when 
attention  has  been  paid  to  the  general  state  of  the  digestive  organs 
by  general  aperient  medicines,  and  antacid  remedies,  such  as  bismuth 
and  soda,  and  pepsine  after  meals,  the  tendency  to  vomiting  may 
abate  without  further  treatment. 

Regulation  of  Diet. — The  careful  regulation  of  the  diet  is  very  im- 
portant. Great  benefit  is  often  derived  from  reco;nmending  the 
patient  not  to  rise  from  the  recumbent  position  in  the  morning  until 
she  has  taken  something.  Half  a  cup  of  milk  and  lime-water,  or  a 
cup  of  strong  coffee,  or  a  little  rum  and  milk,  or  cocoa  and  milk,  or 
even  a  morsel  of  biscuit,  taken  on  waking,  often  has  a  remarkable 
effect  in  diminishing  the  nausea.  When  any  attempt  at  swallowing 
solid  food  brings  on  vomiting,  it  is  better  to  give  up  all  pretence  at 
keeping  to  regular  meals,  and  to  order  such  light  and  easily  assimi- 
lated food,  at  short  intervals,  as  can  be  retained.  Iced  milk  with 
lime  or  soda-water,  given  frequently,  and  not  more  than  a  mouthful 
at  a  time,  will  frequently  be  retained  when  nothing  else  will.  Cold 
beef  Jelly,  a  spoonful  at  a  time,  will  also  be  often  kept  down.  Spark- 
ling koumiss  has  been  strongly  recommended  as  very  useful  in  such 
cases,  and  is  worthy  of  trial.  It  is  well,  however,  to  bear  in  mind, 
in  regulating  the  diet,  that  the  stomach  is  fanciful  and  capricious, 
and  that  the  patient  may  be  able  to  retain  strange  and  apparently 
unlikely  articles  of  food ;  and  that,  if  she  express  a  desire  for  such, 
the  experiment  of  letting  her  have  them  should  certainly  be  tried. 

Medicinal  Treatment. — The  medicines  that  have  been  recommended 
are  innumerable,  and  the  practitioner  will  often  have  to  try  one  after 
the  other  unsuccessfully ;  or  may  find,  in  an  individual  case,  that  a 
remedy  will  prove  valuable  which,  in  another,  may  be  altogether 
powerless.  Amongst  those  most  generally  useful  are  effervescing 
draughts,  containing  from  three  to  five  minims  of  dilute  hydrocyanic 
acid ;  the  creasote  mixture  of  thb  Pharmacopoeia ;  tincture  of  nux 
vomica,  in  doses  of  five  or  ten  minims  ;  single  minim  doses  of  vinum 
ipecacuanhge,  every  hour  in  severe  cases,  three  or  four  limes  daily  in 
those  which  are  less  urgent ;  salicine,  in  doses  of  three  to  five  grains 
three  times  a  day,  recommended  by  Tyler  Smith  ;  oxalate  of  cerium, 
in  the  form  of  pill,  of  which  three  to  five  grains  may  be  given  three 
times  a  day — a  remedy  strongly  advocated  by  Sir  James  Simpson, 
and  which  occasionally  is  of  undoubted  service,  but  more  often  fails ; 
the  compound  pyroxylic  spirit  of  the  London  Pharmacopoeia  in  doses 
of  five  minims  every  four  hours,  with  a  little  compound  tincture  of 
cardamoms,  a  drug  which  is  comparatively  little  known,  but  which 


DISEASES    OF    PREGNANCY.  191 

occasionally  has  a  very  marked  and  beneficial  effect  in  clieckinw 
vomiting ;  o|)iates  in  various  forms — wliicli  sometimes  prove  useful, 
more  often  not — -may  be  administered  either  by  the  mouth  or  in  pills 
containing  from  half  a  grain  to  a  grain  of  opium,  or  in  small  doses 
of  the  solution  of  the  bimeconate  of  morphia  or  of  Eattley's  sedative 
solution,  or  subcutaneously,  a  mode  of  administration  which  is  much 
more  often  successful.  If  there  is  much  tenderness  about  the  epigas- 
trium, one  or  two  leeches  may  be  advantageously  applied,  or  one- 
third  of  a  grain  of  morphia  may  be  sprinkled  on""  the  surface  of  a 
small  blister,  or  cloths  saturated  in  laudanum  may  be  kept  over  the 
pit  of  the  stomach.  The  administration  per  rectum  of  twenty  grains 
of  chloral,  combined  with  the  same  amount  of  bromide  of  potassium, 
in  a  small  enema,  is  said  to  be  very  useful.  In  many  cases  I  have 
found  that  the  application  of  a  spinal  ice-bag  to  the  cervical  vertebrae 
in  the  manner  recommended  by  Dr.  Chapman,  has  checked  the  vom- 
iting when  all  drugs  have  failed.  The  ice  may  be  placed  in  one  of 
Chapman's  spinal  ice-bags,  and  applied  for  half  an  hour  or  an  hour 
twice  or  three  times  a  day.  It  invariably  produces  a  comfortino- 
sensation  of  warmth,  which  is  always  agreeable  to  the  patient.  Ice 
may  be  given  to  suck  ad  libitum^  and  is  very  useful ;  while,  if  there 
be  much  exhaustion,  small  quantities  of  iced  champagne  may  also 
be  given  from  time  to  time. 

Local  Treatment. — Inasmuch  as  the  vomiting  unquestionably  has 
its  origin  in  the  uterus,  it  is  only  natural  that  practitioners  should 
endeavor  to  check  it  by  remedies  calculated  to  relieve  the  irritability 
of  that  organ.     Thus  morphia  in  the  form  of  pessaries  per  vaginam, 

or  belladonna  applied  to  the  cervix,  has  been  recommended   and 

the  former  especially — are  often  of  undoubted  service.  A  pessary 
containing  one-third  to  half  a  grain  of  morphia  may  be  introduced 
night  and  morning,  without  interfering  with  other  methods  of  treat- 
ment. Dr.  Henry  Bennet  directs  especial  attention  to  the  cervix 
which,  he  says,  is  almost  always  congested  and  inflamed,  and  covered 
with  granular  erosions.  This  condition  he  recommends  to  be  treated 
by  the  application  of  nitra|.e  of  silver  through  the  speculum.  Dr. 
Clay,  of  Manchester,  corroborates  this  view,  and  strongly  advocates, 
especially  when  vomiting  continues  in  the  latter  months,  that  one  or 
two  leeches  should  be  applied  to  the  cervix.  Exception  may  fairly 
be  taken  to  both  these  methods  of  treatment  as  being  somewhat 
hazardous,  unless  other  means  have  been  tried  and  failed.  I  have 
little  doubt,  however,  that,  m  many  cases,  a  state  of  uterine  con- 
gestion is  an  important  factor  in  keeping  up  the  unduly  irritable 
condition  of  the  uterine  fibres,  and  an  endeavor  should  always  be 
made  to  lessen  it  by  insisting  on  absolute  rest  in  the  I'ecumbent  pos- 
ture. Of  the  importance  of  this  precaution  in  obstinate  cases  there 
can  be  no  question.  Dr.  Chapman,  of  Norwich,  strongly  recommends 
dilation  of  the  cervix  by  the  finger,  and  states  that  he  has  found  it 
very  serviceable  in  checking  nausea.  It  is  obvious  that  this  treat- 
ment must  be  adopted  with  great  caution,  as,  roughly  performed,  it 
might  lead  to  the  production  of  abortion.  Dr.  Hewitt's  views  as' to 
the  dependence  of  sickness  on  flexions  of  the  uterus,  have  already 


192  PREGNANCY. 

been  adverted  to,  and  reasons  have  been  given  for  doubting  the 
general  correctness  of  his  theory.  It  is  quite  likely,  however,  that 
well-marked  displacements  of  the  uterus,  either  forwards  or  back- 
wards, may  serve  to  intensify  the  irritability  of  the  organ.  Cazeaux 
mentions  an  obstinate  case  immediately  cured  by  replacing  a  retro- 
verted  uterus.  A  careful  vaginal  examination  should,  therefore,  be 
instituted  in  all  intractable  cases,  and  if  distinct  displacement  be  de- 
tected, an  endeavor  should  be  made  to  support  the  uterus  in  its 
normal  axis.  If  retroverted,  a  Hodge's  pessary  may  be  safely  em- 
ployed ;  if  anteverted,  a  small  air-ball  pessary,  as  recommended  by 
Hewitt,  should  be  inserted.  I  believe,  however,  that  such  displace- 
ments are  the  exception  rather  than  the  rule  in  cases  of  severe  sick- 
ness. 

The  importance  of  promoting  nutrition  by  every  means  in  our 
power  should  always  be  borne  in  mind.  The  effervescing  koumiss, 
which  can  now  be  readily  obtained,  I  have  found  of  great  value,  as 
it  can  often  be  retained  when  all  other  aliment  is  rejected.  The  ex- 
haustion produced  by  want  of  food  soon  increases  the  irritable  state 
of  the  nervous  system,  and,  if  the  stomach  will  not  retain  anything, 
we  can  only  combat  it  by  occasional  nutrient  enemata  of  strong  beef 
tea,  yolk  of  egg,  and  the  like. 

The  production  of  Artificial  Ahortion.- — Finally,  in  the  worst  class 
of  cases,  when  all  treatment  has  failed,  and  when  the  patient  has 
fallen  into  the  condition  of  extreme  prostration  already  described,  we 
may  be  driven  to  consider  the  necessity  of  producing  abortion.  For- 
tunately cases  justifying  this  extreme  resource  are  of  great  rarity, 
but  nevertheless  there  is  abundant  evidence  that,  every  now  and  then 
women  do  die  from  uncontrollable  vomiting,  whose  lives  might  have 
been  saved  had  the  pregnancy  been  brought  to  an  end.  The  value 
of  artificial  abortion  has  been  abundantly  proved.  Indeed,  it  is  re- 
markable how  rapidly  the  serious  symptoms  disappear  when  the 
uterus  is  emptied,  and  the  tension  of  the  uterine  fibres  lessened.  It 
has  fortum,tely  but  rarely  fallen  to  my  lot  to  have  to  perform  this 
operation  for  intractable  vomiting.  In  one  such  case  the  patient  was 
reduced  to  a  state  of  the  utmost  prostration,  having  kept  hardly  any 
food  on  her  stomach  for  many  weeks,  and  when  I  first  saw  her  she 
was  lying  in  a  state  of  low  muttering  d-^lirium.  Within  a  few  hours 
after  abortion  was  induced  all  the  threatening  symptoms  had  disap- 
peared, the  vomiting  had  entirely  ceased,  and  she  was  next  day  able 
to  retain  and  absorb  all  that  was  given  to  her.  The  value  of  the 
operation,  therefore,  I  believe  to  be  undoubted.  Where  it  has  failed, 
it  seems  to  have  been  on  account  of  undue  delay.  Owing  to  the 
natural  repugnance  which  all  must  feel  towards  this  plan,  it  has  gene- 
rally been  postponed  until  the  patient  has  been  too  exhausted  to  rally. 
If,  therefore,  it  is  done  at  all,  it  should  be  before  prostration  has  ad- 
vanced so  far  as  to  render  the  operation  useless.  In  these  cases  the 
obvious  indication  is  to  lessen  the  tension  of  the  uterus  at  once,  and 
therefore  the  membranes  should  be  punctured  by  the  uterine  sound, 
so  as  to  let  the  liquor  amnii  drain  away,  and  this  may  of  itself  be 
sufhcient  to  accomplish  the  desired  effect.     It  is  almost  needless  to 


DISEASES    OF    PREGNANCY.  193 

add  that  no  one  would  be  justified  in  resorting  to  this  expedient 
without  liaving  liis  opinion  lortilied  by  consultulion  with  a  iellow- 
practitioner. 

Other  disorders  of  the  digestive  system  may  give  rise  to  eonsiderable 
discomfort  but  not  to  the  serious  peril  attending  obstinate  vomiting. 
Amongst  them  are  loss  of  appetite,  acidity  and  heartburn,  flatulent 
distension  and  sometimes  a  capricious  appetite,  which  assumes  the 
form  of  lono-ino-  for  strange  and  even  disgusting  articles  of  diet.  As- 
sociated witli  these  conditions  there  is  generally  derangement  of  the 
whole  intestinal  tract,  indicated  by  furred  tongue  and  sluggish  bowels, 
and  they  are  best  treated  by  remedies  calculated  to  restore  a  healthy 
condition  of  the  digestive  organs,  such  as  a  hght  easily  digested  diet, 
mineral  acids,  vegetable  bitters,  occasional  aperients,  bismuth  and 
soda,  and  pepsine.  The  indications  for  treatment  are  not  different 
from  those  which  accompany  the  same  symptoms  in  the  non-pregnant 
state. 

Diarrhoea  is  an  occasional  accompaniment  of  pregnancy,  often  de- 
pending on  errors  of  diet.  When  excessive  and  continuous  it  has  a 
decided  tendency  to  induce  uterine  contractions,  and  I  have  frequently 
observed  premature  labor  to  follow  a  sharp  attack  of  diarrhoea.  It 
should,  therefore,  not  be  neglected ;  and,  if  at  all  excessive,  should 
be  checked  by  the  usual  means,  such  as  chalk  mixture  with  aromatic 
confection,  and  small  doses  of  laudanum  or  chlorodyne.  The  possi- 
bility of  apparent  diarrhoea  being  associated  with  actual  constipation, 
the  fluid  matter  finding  its  way  past  the  solid  materials  blocking  up 
the  intestines,  should  be  borne  in  mind. 

Constipation  is  much  more  common,  and  is  indeed  a  very  general 
accompaniment  of  pregnancy,  even  in  women  who  do  not  suffer  from 
it  at  other  times.  It  partly  depends  on  the  mechanical  interference 
of  the  gravid  uterus  with  the  proper  movements  of  the  intestines, 
and  partly  on  defective  innervation  of  the  bowels  resulting  from  the 
altered  state  of  the  blood.  The  first  indication  will  be  to  remedy 
this  defect  by  appropriate  diet,  such  as  fresh  fruits,  brown  bread,  oat- 
meal porridge,  etc.  Some  medicinal  treatment  will  also  be  necessary, 
and,  in  selecting  the  drugs  to  be  used,  care  should  be  taken  to  choose 
such  as  are  mild  and  unirritating  in  their  action,  and  tend  to  improve 
the  tone  of  the  muscular  coats  of  the  intestine.  A  small  quantity 
of  aperient  mineral  water  in  the  early  morning,  such  as  the  Hunyadi, 
Frederickshalle,  or  Pullna  water,  often  answers  very  well ;  or  an  oc- 
casional dose  of  the  confection  of  sulphur  ;  or  a  pill  containing  three 
or  four  grains  of  the  extract  of  colocynth,  with  a  quarter  of  a  grain 
of  the  extract  of  nux  vomica,  and  a  grain  of  extract  of  hyoscyamus 
at  bedtime ;  or  a  teaspoonful  of  the  compound  liquorice  powder  in 
milk  at  bedtime.  Constipation  is  also  sometimes  effectually  com- 
bated by  administering,  twice  daily,  a  pill  containing  a  couple  of 
grains  of  the  inspissated  ox-gall,  with  a  quarter  of  a  grain  of  extract 
of  belladonna.  Enemata  of  soap  and  water  are  often  very  useful,  and 
have  the  advantage  of  not  disturbing  the  digestion.  In  the  latter 
months  of  pregnancy,  especially  in  the  few  weeks  preceding  delivery 
the  irritation  produced  by  the  collection  of  hardened  feces  in  the 


194  PREGNANCY. 

bowel  is  a  not  infrequent  cause  of  the  annoying  false  pains  which  then 
so  commonly  trouble  the  patient.  In  order  to  relieve  them,  it  will  be 
necessary  to  empty  the  bowels  thoroughly  by  an  aperient,  such  as  a 
good  dose  of  castor  oil,  to  which  fifteen  or  twenty  minims  of  laudanum 
may  be  advantageously  added.  Should  the  rectum  become  loaded 
with  scybalous  masses,  it  may  be  necessary  to  break  down  and  re- 
move them  by  mechanical  means,  provided  we  are  unable  to  effect 
this  by  copious  enemata. 

Htmorrlioids. — The  loaded  state  of  the  rectum  so  common  in  preg- 
nancy, combined  with  the  mechanical  effect  of  the  pressure  of  the 
gravid  uterus  on  the  hemorrhoidal  veins,  often  produces  very  trou- 
blesome symptoms  from  piles.  In  such  cases  a'  regular  and  gentle 
evacuation  of  the  bowels  should  be  secured  daily,  so  as  to  lessen  as 
much  as  possible  the  congestion  of  the  veins.  Au}^  of  the  aperients 
already  mentioned,  especially  the  sulphur  electuary,  naay  be  used. 
Dr.  Fordyce  Barker^  insists  that,  contrary  to  the  usual  impression, 
one  of  the  best  remedies  for  this  purpose  is  a  pill  containiug  a  grain 
or  a  grain  and  a  half  of  powdered  aloes,  with  a  quarter  of  a  grain  of 
extract  of  nux  vomica,  and  that  castor  oil  is  distinctly  prejudicial, 
and  apt  to  increase  the  symptoms.  I  have  certainly  found  it  answer 
well  in  several  cases.  When  the  piles  are  tender  and  swollen,  they 
should  be  freely  covered  with  an  ointment  consisting  of  four  grains 
of  muriate  of  morphia  to  an  ounce  of  simple  ointment,  or  with  the 
Ung.  Gallge  c.  opio  of  the  Pharmacopoeia  ;  and,  if  protruded,  an  at- 
tempt should  be  made  to  push  them  gently  above  the  sphincter,  by 
which  they  are  often  unduly  constricted.  Relief  may  also  be  ob- 
tained by  frequent  hot  fomentations,  and  sometimes,  when  the  piles 
are  much  swollen,  it  will  be  found  useful  to  j)uncture  them,  so  as  to 
lessen  the  congestion,  before  any  attempt  at  reduction  is  made. 

Ptyalism. — A  profuse  discharge  from  the  salivary  glands  is  an 
occasional  distressing  accompaniment  of  pregnancy.  It  is  generally 
confined  to  the  early  months,  but  it  occasionally  continues  during  the 
whole  period  of  gestation,  and  resists  all  treatment,  only  ceasing 
when  delivery  is  over.  Under  such  circumstances  the  discharge  of 
saliva  is  sometimes  enormous,  amounting  to  several  quarts  a  day, 
and  the  distress  and  annoyance  to  the  patient  are  very  great.  In  one 
case  under  my  care  the  saliva  poured  from  the  mouth  all  day  long, 
and  for  several  months  the  patient  sat  with  a  basin  constantly  by  her 
side,  incessantly  emptying  her  mouth,  until  she  was  reduced  to  a 
condition  giving  rise  to  really  serious  anxiety.  This  profuse  saliva- 
tion is,  no  doubt,  a  purely  nervous  disorder,  and  not  readily  con- 
trolled by  remedies.  Astringent  gargles,  containing  tannin  and 
chlorate  of  potass,  frequent  sucking  of  ice,  or  of  tannin  lozenges,  in- 
halation of  turpentine  and  creasote,  counter-irritation  over  the  sali- 
vary glands  by  blisters  or  iodine,  the  bromides,  opium  internally, 
may  all  be  tried  in  turn,  but  none  of  them  can  be  depended  on  with 
any  degree  of  confidence. 

Toothache  and  Caries  of  the  Teeth. — Severe  dental  neuralgia  is  also 

'  The  Puerperal  Diseases,  p.  33. 


DISEASES    OF    PREGNANCY.  195 

a  frequent  accompaniment  of  pregnancy,  especially  in  the  early 
months.  When  purely  neuralgic,  quinine  in  tolerably  large  doses  is 
the  best  remedy  at  our  disposal;  but  not  infrequently,  it  depends  on 
actual  caries  of  the  teeth,  and  attention  should  always  be  paid  to  the 
condition  of  the  teeth,  when  facial  neuralgia  exists.  There  is  no 
doubt  that  pregnancy  predisposes  to  caries,  and  the  observation  of 
this  fact  has  given  rise  to  the  old  proverb,  ''for  every  cliild  a  tooth." 
Mr.  Oakley  Coles,  in  an  interesting  paper'  on  the  condition  of  the 
mouth  and  teeth  during  pregnancy,  refers  the  prevalence  of  caries  to 
the  coexistence  of  acid  dyspepsia,  causing  acidity  of  the  oral  secre- 
tions. There  is  much  unreasonable  dread  amongst  practitioners  as 
to  interfering  with  the  teeth  during  pregnancy,  and  some  recommend 
that  all  operations,  even  stopping,  should  be  postponed  until  after 
delivery.  It  seems  to  me  certain  that  the  suffering  of  severe  tooth- 
ache is  likely  to  give  rise  to  far  more  severe  irritation  than  the  opera- 
tion required  for  its  relief,  and  I  have  frequently  seen  badly  decayed 
teeth  extracted  during  pregnancy,  and  with  only  a  beneficial  result. 

Affections  of  the  Respiratory  Organs. — Amongst  the  derangements 
of  the  respiratory  organs,  one  of  the  most  common  is  spasmodic 
cough,  which  is  often  excessively  troublesome.  Like  many  other  of 
the  sympathetic  derangements  accompanying  gestation,  it  is  purely 
nervous  in  character,  and  is  unaccompanied  by  elevated  temperature, 
quickened  pulse,  or  any  distinct  auscultatory  phenomena.  In  char- 
acter it  is  not  unlike  whooping-cough.  The  treatment  must  obviously 
be  guided  by  the  character  of  the  cough.  Expectorants  are  not  likely 
to  be  of  service,  while  benefit  may  be  derived  from  some  of  the  anti- 
spasmodic class  of  drugs,  such  as  belladonna,  hydrocj^anic  acid,  opi- 
ates, or  bromide  of  potassium.  Such  remedies  may  be  tried  in  suc- 
cession, but  will  often  be  found  to  be  of  little  value  in  arresting  the 
cough.  Dyspnoea  may  also  be  nervous  in  character,  and  sometimes 
symptoms,  not  unlike  those  of  spasmodic  asthma,  are  produced. 
Like  the  other  sympathetic  disorders,  it,  as  well  as  nervous  cough, 
is  most  frequently  observed  during  the  early  months.  There  is  an- 
other form  of  dyspnoea,  not  uncommonly  met  with,  which  is  the  me- 
chanical result  of  the  interference  with  the  action  of  the  diaphragm 
and  lungs  by  the  pressure  of  the  enlarged  uterus.  Hence  this  is 
most  generally  troublesome  in  the  latter  months,  and  continues  unre- 
lieved until  delivery,  or  until  the  sinking  of  the  uterine  tumor  which 
immediately  precedes  it.  Beyond  taking  care  that  the  pressure  is 
not  increased  by  tight  lacing  or  injudicious  arrangement  of  the 
clothes,  there  is  little  that  can  be  done  to  relieve  this  form  of  breath- 
lessness. 

[In  some  instances,  the  difficulty  of  respiration  is  particularly  dis- 
tressing when  the  patient  attempts  to  lie  down  in  bed;  and  sleep  is 
rendered  broken  and  unrefreshing.  In  such  cases  two  points  are 
indicated:  we  must  elevate  the  chest,  and  at  the  same  time  relieve 
the  tension  of  the  abdomen.  This  is  best  accomplished  by  the  use 
of  an  inclined  plane,  in  the  form  of  a  wide  board  padded  with  pillows, 

'  Trans,  of  the  Odontological  Society. 


196  PREGNANCY. 

resting  on  the  head  and  middle  of  the  bed  at  its  two  ends.  The 
patient  is  to  rest  her  back  upon  this,  in  a  half-reclining  position, 
and  have  her  knees  elevated  with  a  pillow  under  them,  on  which 
she  virtually,  as  it  were,  sits.  This  I  have  found  to  give  great 
relief,  especially  to  primiparte,  who  are  apt  to  suffer  from  diaphragm- 
atic pressure  and  abdominal  resistance.  Inunction  of  the  abdomen 
will  also  be  found  of  value. — Ed.] 

Palpitation^  like  dyspnoea,  may  be  due  either  to  sympathetic  dis- 
turbance, or  to  mechanical  interference  with  the  proper  action  of  the 
heart.  When  occurring  in  weakly  women  it  may  be  referred  to  the 
functional  derangements  which  accom[)any  the  chlorotic  condition 
of  the  blood  often  associated  with  pregnancy,  and  is  then  best  reme- 
died by  a  general  tonic  regimen,  and  the  administration  of  ferruginous 
preparations.  At  other  times  anti- spasmodic  remedies  may  be  indi- 
cated, but  it  is  seldom  sufficiently  serious  to  call  for  much  special 
treatment. 

Syncope. — Attacks  of  fainting  are  not  rare,  especially  in  delicate 
women  of  highly-developed  nervous  temperament,  and  are  perhaps 
most  common  at  or  about  the  period  of  quickening,  although  some- 
times lasting  through  the  whole  pregnancy.  In  most  cases  these 
attacks  cannot  be  classed  as  cardiac,  but  are  more  probably  nervous 
in  character,  and  they  are  rarely  associated  with  complete  abolition 
of  consciousness.  They  rather,  therefore,  resemble  the  condition 
described  by  the  older  authors  as  lypjoiliemia.  The  patient  lies  in  a 
semi-unconscious  condition  with  a  feeble  pulse  and  widely-dilated 
pupils,  and  this  state  lasts  for  varying  periods,  from  a  ^q\y  minutes 
to  half  an  hour  or  more.  In  one  very  troublesome  case  under  my 
care  they  often  recurred  as  frequently  as  three  or  four  times  a  day. 
I  have  observed  that  they  rarely  occur  Avhen  the  more  common  sym- 
pathetic phenomena  of  pregnancy,  especially  vomiting,  are  present. 
Sometimes  they  terminate  with  the  ordinary  sjmiptoms  of  hj^steria 
such  as  sobbing.  The  treatment  should  consist  during  the  attack  in 
the  administration  of  diffusible  stimulants,  such  as  ether,  sal-volatile, 
and  valerian,  the  patient  being  placed  in  the  recumbent  position  with 
the  head  low.  If  frequently  repeated  it  is  unadvisable  to  attempt  to 
rally  the  patient  by  the  too  free  administration  of  stimulants.  In  the 
intervals  a  generally  tonic  regimen,  and  the  administration  of  ferru- 
ginous remedies,  are  indicated.  If  they  recur  with  great  frequency 
the  daily  application  of  the  spinal  ice-bag  has  proved  of  much  ^service. 

Extreme  Anaemia  and  Chlorosis. — In  connection  with  disorders  of 
the  circulatory  system  may  be  noticed  those  which  depend  on  the 
state  of  the  blood.  Tlie  altered  condition  of  the  blood,  which  has 
already  been  described  as  a  physiological  accompaniment  of  pregnancy 
(p.  132),  is  sometimes  carried  to  an  extent  which  may  fairly  be  called 
morbid;  and,  either  on  account  of  the  deficiency  of  blood-corpuscles, 
or  from  the  increase  in  its  watery  constituents,  a  state  of  extreme 
anajmia  and  chlorosis  may  be  developed.  This  may  be  sometimes 
carried  to  a  very  serious  extent.     Thus  Gusserow^  records  five  cases 

1  Arch.  f.  Gyn.,  ii.  2,  1871. 


DISEASES    OF    PREGNANCY.  197 

in  which  nothing  lout  excessive  antemia  could  be  detected,  all  of  which 
ended  fatally.  Generally  when  such  symptoms  have  been  carried  to 
an  extreme  extent,  the  patient  has  been  in  a  state  of  chlorosis  before 
pregnancy.  The  treatment  must,  of  course,  be  calculated  to  improve 
the  general  nutrition,  and  enrich  the  impoverished  blood;  a  light 
and  easily  assimilated  diet,  milk,  eggs,  beef-tea,  and  animal  food — if 
it  can  be  taken — attention  to  the  proper  action  of  the  bowels,  a  due 
amount  of  stimulants,  and  abundance  of  fresh  air,  will  he  the  chief 
indications  in  the  general  management  of  the  case.  Medicinallv,  fer- 
ruginous pre]mrations  will  be  required.  Some  practitioners  object, 
apparently  without  sufficient  reason,  to  the  administration  of  iron 
during  pregnancy,  as  liable  to  promote  abortion.  This  unfounded 
prejudice  may  probably  be  traced  to  the  supposed  emmenagogue  prop- 
erties of  the  preparations  of  iron ;  but,  if  the  general  condition  of  the 
patient  indicate  such  medication,  they  may  be  administered  without 
any  fear.  Preparations  of  phosphorus,  such  as  the  phosphide  of 
zinc,  or  free  phosphorus  in  capsules,  also  promise  favorably,  and 
are  w^ell  worthy  of  trial. 

(Edema  associated  ivith  Hydrsemia. — Some  of  the  more  aggravated, 
cases  are  associated  with  a  considerable  amount  of  serous  effusion 
into  the  cellular  tissue,  generally  limited  to  the  lower  extremities, 
but  occasionally  extending  to  the  arms,  face,  and  neck,  and  even 
producing  ascites  and  pleuritic  effusion.  Under  the  latter  circum- 
stances this  complication  is,  of  course,  of  great  gravity,  and  it  is  said, 
that  after  delivery  the  disappearance  of  the  serous  effusion  may  be 
accompanied  by  metastasis  of  a  fatal  character  to  the  lungs  or  the 
nervous  centres.  This  form  of  oedema  must  be  distinguished  from 
the  slight  oedematous  swelling  of  the  feet  and  legs  so  commonly  ob- 
served as  a  mechanical  result  of  the  pressure  of  the  gravid  uterus, 
and  also  from  those  cases  of  oedema  associated  with  albuminuria. 
The  treatment  must  be  directed  to  the  cause,  while  the  disappearance 
of  the  effusion  may  be  promoted  by  the  administration  of  diuretic 
drinks,  the  occasional  use  of  saline  aperients,  and  rest  in  the  hori- 
zontal position. 

Albuminuria. — The  existence  of  albumen  in  the  urine  of  pregnant 
women  has  for  many  years  attracted  the  attention  of  obstetricians, 
and  it  is  now  well  known  to  be  associated,  in  waj^s  still  imperfectly 
understood,  with  many  important  puerperal  diseases.  Its  presence 
in  most  cases  of  puerperal  eclampsia  was  long  ago  pointed  out  by 
Lever  in  this  country  and  Rayer  in  France,  and  its  association  with 
this  disease  gave  rise  to  the  theory  of  the  dependence  of  the  convul- 
sion on  urtemia,  which  is  still  generally  entertained.  It  has  been 
shown  of  late  years,  especially  by  Braxton  Hicks,  that  this  associa- 
tion is  by  no  means  so  universal  as  was  supposed;  or  rather  that,  in 
some  cases,  the  albuminuria  follows  and  does  not  precede  the  convul- 
sions, of  which  it  might  therefore  be  supposed  to  be  the  consequence 
rather  than  the  cause;  so  that  further  investigations  as  to  these  par- 
ticular points  are  still  required.  Modern  researches  have  shown  that 
there  is  an  intimate  connection  between  many  other  affections  and 
albuminuria;  as,  for  example,  certain  forms  of  paralysis,  either  of 


198  PREGNANCY. 

special  nerves,  as  puerperal  amaurosis,  or  of  tlie  spinal  system; 
cephalalgia  and  dizziness ;  puerperal  mania ;  and  possibly  hemor- 
rhage. It  cannot,  therefore,  be  doubted  that  albuminuria  in  the 
pregnant  woman  is  liable,  at  any  rate,  to  be  associated  with  grave 
disease,  although  the  present  state  of  our  knowledge  does  not  enable 
us  to  define  very  distinctly  its  precise  mode  of  action. 

Causes  of  Puerperal  Albuminuria. — The  presence  of  albumen 
in  the  urine  of  pregnant  women  is  far  from  a  rare  phenomenon. 
Blot  and  Litzman  met  with  albuminuria  in  20  per  cent,  of  pregnant 
women,  which  is,  moreover,  far  above  the  estimate  of  other  authors; 
Fordyce  Barlvcr^  thinks  it  occurs  in  about  1  out  of  25  cases,  or  4  per 
cent.,  while  Hofmier^  found  it  in  137  out  of  5000  deliveries  in  the 
Berlin  Gnoekolical  Institution,  or  2.71  per  cent.  As  in  the  large 
majority  of  these  cases,  it  rapidly  disappears  after  delivery,  it  is 
obvious  that  its  presence  must,  in  a  large  pro[)ortion  of  cases,  depend 
on  temporary  causes,  and  has  not  always  the  same  serious  importance 
as  in  the  non-pregnant  state.  This  is  further  proved  by  the  undoubted 
fact  that  albumen,  rapidly  disappearing  after  delivery,  is  often  found 
in  urine  of  pregnant  women  who  go  to  term,  and  pass  through  labor 
without  any  unfavorable  symptoms. 

Pressure  hy  the  QravidUterus. — The  obvious  fact  that  in  pregnancy 
the  vessels  supplying  the  kidneys  are  subjected  to  mechanical  pres- 
sure from  the  gravid  uterus,  and  that  congestion  of  the  venous  circu- 
lation of  those  viscera  must  necessarily  exist  to  a  greater  or  less 
degree,  suggests  that  here  we  may  find  an  explanation  of  the  frequent 
occurrence  of  albuminuria.  This  view  is  farther  strengthened  by  the 
fact  that  the  albumen  rarely  appears  until  after  the  fifth  month,  and, 
therefore,  not  until  the  uterus  has  attained  a  considerable  size ;  and 
also  that  it  is  comparatively  more  frequeiitly  met  with  in  primiparse, 
in  whom  the  resistance  of  the  abdominal  parictes,  and  consequent 
pressure,  must  be  greater  than  in  women  who  have  already  borne 
children.  It  is,  indeed,  probable  that  pressure  and  consequent  venous 
congestion  of  the  kidneys  have  an  important  influence  in  its  produc- 
tion ;  but  there  must  be,  as  a  rule,  some  other  factor  in  operation, 
since  an  equal  or  even  greater  amount  of  pressure  is  often  exerted 
by  ovarian  and.  fibroid  tumors,  without  any  such  consequences. 

Altered  State  of  the  Blood. — This  is  probably  to  be  found  in  the 
altered  condition  of  the  blood,  which,  on  account  of  the  unusual  call 
for  nutritive  supply  on  the  part  of  the  foetus,  contains  an  excess  of 
albuminous  material.  Hence  we  have  two  factors  always  at  work  in 
the  pregnant  woman,  both  predisposing  to  the  escape  of  albumen, 
viz.,  a  turgid  state  of  the  renal  venous  sj'stem,  and  a  super-albumi- 
nous condition  of  the  blood.  But  in  the  large  majority  of  cases, 
although  these  conditions  are  present,  no  albuminuria  exists,  and  they 
must,  therefore,  be  looked  upon  as  predisposing  causes,  to  which  some 
other  is  added  before  the  albumen  escapes  from  the  vessels.  AYhat 
this  is  generally  escapes  our  observation,  but  probably  any  condition 

'  American  Joui-nal  of  Obstetrics,  July,  1878. 
2  Berlin  Klin.  Wocli.,  Sept.  1878. 


DISEASES    OF    PREGNANCY.  199 

producing  sudden  hjperacmia  of  the  kidneys,  and  giving  rise  to  a 
state  analogous  to  tl^e  first  stage  of  Bright's  disease — sucli,  for  ex- 
ample, as  sudden  exposure  to  cold  and  impeded  cutaneous  action — 
may  be  sufficient  to  set  a  light  to  the  match  already  prepared  by  the 
existence  of  pregnancy.  In  addition  to  these  temporary  causes  it 
must  not  be  forgotten  that  pregnancy  may  supervene  in  a  patient 
already  suffering  from  Bright's  disease,  when  of  course  the  albumen 
will  exist  in  the  urine  from  the  commencement  of  gestation. 

The  Effects  of  Pueiyeral  Alhutninuria. — The  various  diseases  asso- 
ciated with  the  presence  of  albumen  in  the  urine  will  require  sepa- 
rate consideration.  Some  of  these,  especially  puerperal  eclampsia,  are 
amongst  the  most  dangerous  complications  of  pregnancy.  Others,  such 
as  paralysis,  cephalalgia,  dizziness,  may  also  be  of  considerable  gravity. 
The  precise  mode  of  their  production,  and  whether  they  can  be  traced, 
as  is  generally  believed,  to  the  retention  of  urinary  elements  in  the 
blood,  either  urea  or  free  carbonate  of  ammonia  produced  by  its  de- 
composition, or  whether  the  two  are  only  common  results  of  some 
undetermined  cause,  will  be  considered  when  we  come  to  discuss 
puerperal  convulsions.  Whatever  view  may  ultimately  be  taken  on 
these  points,  it  is  sufficiently  obvious  that  albuminuria  in  a  pregnant 
woman  must  constantly  be  a  source  of  much  anxiety,  and  must  induce 
us  to  look  forward  with  considerable  apprehension  to  the  termination 
of  the  case. 

Prognosis. — We  are  scarcely  in  possession  of  a  sufficiently  large 
number  of  observations  to  justify  any  very  accurate  conclusions  as 
to  the  risk  attending  albuminuria  during  pregnancy,  but  it  is  certainly 
by  no  means  slight.  Hofmeir  believes  that  albuminuria  is  a  most 
severe  complication  both  for  woman  and  child,  even  when  uncom- 
plicated with  eclampsia.  The  prognosis,  he  thinks,  depends  on 
whether  it  is  acute  in  its  onset,  that  is,  coming  on  within  a  few  days 
of  labor,  or  is  extended  over  several  weeks.  The  former  is  more 
likely  to  pass  entirely  away  after  delivery,  while  in  the  latter  there 
is  more  risk  of  the  morbid  state  of  the  kidneys  becoming  permanent, 
and  leading  to  the  establishment  of  Bright's  disease  after  the  preg- 
nancy is  over.  Goubeyre  estimated  that  49  per  cent,  of  primiparge 
who  have  albuminuria,  and  who  escape  eclampsia,  die  from  morbid 
conditions  traceable  to  the  albuminuria.  This  conclusion  is  prob- 
ably much  exaggerated,  but  if  it  even  approximate  to  the  truth,  the 
danger  must  be  very  great. 

Tendency  to  produce  Abortion. — Besides  the  ultimate  risk  to  the 
mother,  albuminuria  strongly  predisposes  to  abortion,  no  doubt  on 
account  of  the  imperfect  nutrition  of  the  foetus  by  blood  impoverished 
by  the  drain  of  albuminous  materials  through  the  kidneys.  This 
fact  has  been  observed  by  many  writers.  A  good  illustration  of  it 
is  given  by  Tanner,^  who  states  that  four  out  of  seven  women  he  at- 
tended suffering  from  Bright's  disease  during  pregnancy,  aborted,  one 
of  them  three  times  in  succession. 

Syraptoms. — The  symptoms   accompanying  albuminuria  in  preg- 

'  Signs  and  Diseases  of  Pregnancy,  p.  428. 


200  PREGNANCY. 

nancy  are  by  no  means  uniform  or  constantly  present.  That  whicli 
most  frequently  causes  suspicion  is  the  anasarca — ^uot  only  the  oecle- 
matous  swelling  of  the  lower  limbs  which  is  so  common  a  consequence 
of  the  pressure  of  the  gravid  uterus,  but  also  of  the  face  and  upper 
extremities.  Any  puffiness  or  infiltration  about  the  face,  or  any 
oedema  about  the  hands  or  arms,  should  always  give  rise  to  suspicion, 
and  lead  to  a  careful  examination  of  the  urine.  Sometimes  this  is 
carried  to  an  exaggerated  degree,  so  that  there  is  anasarca  of  the 
whole  body. 

Anomalous  nervous  symptoms — such  as  headache,  transient  dizzi- 
ness, dimness  of  vision,  spots  before  the  eyes,  inability  to  see  objects 
distinctly,  sickness  in  women  not  at  other  times  suffering  from 
nausea,  sleeplessness,  irritability  of  temper — are  also  often  met  with, 
sometimes  to  a  slight  degree,  at  others  very  strongly  developed,  and 
should  always  arouse  suspicion.  Indeed,  knowing  as  we  do  that 
many  morbid  states  may  be  associated  with  albuminuria,  we  should 
make  a  point  of  carefully  examining  the  urine  of  all  patients  in 
whom  any  unusually  morbid  phenomena  show  themselves  during 
pregnancy. 

Character  of  the  Urine. — The  condition  of  the  urine  varies  con- 
siderably, but  it  is  generally  scanty  and  highly  colored,  and,  in  addi- 
tion to  the  albumen,  especially  in  cases  in  which  the  albuminuria 
has  existed  for  some  time,  we  may  find  epithelium  cells,  tube  casts, 
and  occasionally  blood  corpuscles. 

Treatment. — The  treatment  must  be  based  on  what  has  been  said 
as  to  the  causes  of  the  albuminuria.  Of  course  it  is  out  of  our  power 
to  remove  the  pressure  of  the  gravid  uterus,  except  by  inducing 
labor  ;  but  its  effects  may  at  least  be  lessened  by  remedies  tending 
to  promote  an  increased  secretion  of  urine,  and  thus  diminishing  the 
congestion  of  the  renal  vessels.  The  administration  of  saline  diure- 
tics, such  as  the  acetate  of  potash,  or  bitartrate  of  potash,  the  latter 
being  given  in  the  form  of  the  well-known  imperial  drink,  will  best 
answer  this  indication.  The  action  of  the  bowels  may  be  solicited 
by  purgatives  producing  watery  motions,  such  as  occasional  doses  of 
the  compound  jalap  powder.  Dry  cupping  over  the  loins,  frequently 
repeated,  has  a  beneficial  effect  in  lessening  the  renal  hypersemia. 
The  action  of  the  skin  should  also  be  promoted  by  the  use  of  the 
vapor  bath,  and  with  this  view  the  Turkish  bath  may  be  employed 
with  great  benefit  and  perfect  safety.  Jaborandi  and  pilocarpin  have 
been  given  for  this  purpose,  but  have  been  found  by  Fordyce  Barker 
to  produce  a  dangerous  degree  of  depression.  The  next  indication  is 
to  improve  the  condition  of  the  blood  by  appropriate  diet  and  medi- 
cation. A  very  light  and  easily  assimilated  diet  should  be  ordered, 
of  which  milk  should  form  the  staple.  Tarnier^  has  recorded  several 
cases  in  which  a  purely  milk  diet  was  very  successful  in  removing 
albuminuria.  With  the  milk,  which  should  be  skimmed,  we  may 
allow  white  of  egg,  or  a  little  white  fish.  The  tincture  of  the  per- 
chloride  of  iron  is  the  best  medicine  we  can  give,  and  it  may  be  ad- 

'  Annal.  de  Gynec,  Jan.  1876. 


DISEASES    OF    PREGNANCY.  201 

vantageoQsly  combined  with  small  doses  of  tincture  of  digitalis,  which, 
acts  as  an  excellent  diuretic. 

Question  of  Inducing  Lalor. — Finally,  in  obstinate  cases  we  shall 
have  to  consider  the  advisability  of  inducing  premature  labor.  The 
propriety  of  this  procedure  in  the  albuminuria  of  pregnancy  has  of 
late  years  been  much  discussed.  Spiegclberg*  is  opposed  to  it,  while 
Barker^  thinks  it  should  only  be  resorted  to  "  when  treatment  has 
been  thoroughly  and  perseveringly  tried  without  success  for  the  re- 
moval of  symptoms  of  so  grave  a  character  that  their  continuance 
would  result  in  the  death  of  the  patient."  Hofmeir,^  on  the  other 
hand,  is  in  favor  of  the  operation  which  he  does  not  think  increases 
the  risk  of  eclampsia,  and  may  avert  it  altogether.  I  believe  that, 
having  in  view  the  undoubted  risks  which  attend  this  complication, 
the  operation  is  unquestionably  indicated,  and  is  perfectly  justifiable, 
in  all  cases  attended  with  symptoms  of  serious  gravity.  It  is  not 
easy  to  lay  down  any  definite  rules  to  guide  our  decision  ;  but  I 
should  not  hesitate  to  adopt  this  resource  in  all  cases  in  which  the 
quantity  of  albumen  is  considerable  and  progressively  increasing, 
and  in  which  treatment  has  failed  to  lessen  the  amount;  and,  above 
all,  in  every  case  attended  with  threatening  symptoms,  such  as  severe 
headache,  dizziness,  or  loss  of  sight.  The  risks  of  the  operation  are 
infinitesimal  compared  to  those  which  the  patient  would  run  in  the 
event  of  puerperal  convulsions  supervening,  or  chronic  Bright's  dis- 
ease becoming  established.  As  the  operation  is  seldom  likely  to  be 
indicated  until  the  child  has  reached  a  viable  age,  and  as  the  albu- 
minuria places  the  child's  life  in  danger,  we  are  quite  justified  in 
considering  the  mother's  safety  alone  in  determining  on  its  perform- 
ance. 


CHAPTEE   VIII. 

DISEASES    OF    PREGNANCY  (CONTINUED). 

Disorders  of  the  Nervous  System. — There  are  many  disorders  of 
the  nervous  system  met  with  during  the  course  of  pregnancy. 
Among  the  most  common  are  morbid  irritability  of  temper,  or  a  state 
of  mental  despondency  and  dread  of  the  results  of  the  labor,  some- 
times almost  amounting  to  insanity,  or  even  progressing  to  actual 
mania.  These  are  but  exaggerations  of  the  highly  susceptible  state 
of  the  nervous  system  generally  associated  with  gestation.  Want  of 
sleep  is  not  uncommon,  and,  if  carried  to  any  great  extent,  may  pro- 
duce serious  trouble  from  the  irritability  and  exhaustion  it  produces 

'  Lehrhiicli.  des  GeLiirt.  ^  Amer.  Jour,  of  Obstet.,  July,  1878. 

^  Op.  cit. 
14 


202  PREGNANCY. 

In  such  cases  we  should  endeavor  to  lessen  the  excitable  state  of 
the  nerves,  bj  insisting  on  the  avoidance  of  late  hours,  over-much 
society,  exciting  amusements,  and  the  like :  while  it  may  be  essential 
to  promote  sleep  by  the  administration  of  sedatives,  none  answering 
so  well  as  the  chloral  hydrate,  in  combination  with  large  doses  of 
the  bromide  of  potassium,  which  greatly  intensifies  its  hypnotic 
effects.  [I  have  for  several  years  made  use  of  the  bromide  of  sodium 
very  extensively  for  the  purpose  of  quieting  nervous  excitability  and 
securing  sleep.  This  salt  is  more  soluble  than  that  of  potash  ;  has  a 
larger  equivalent  of  bromine,  and  hence  more  hypnotic  power ;  is 
more  grateful  to  the  stomach,  and  more  purely  salt-like  in  character. 
Its  price  in  the  United  States,  is  no  longer  an  obstacle  to  its  extensive 
use. — Ed.] 

Headaches  and  Neuralgias. — Severe  headaches  and  various  intense 
neuralgite  are  common.  Amongst  the  latter  the  most  frequently 
met  with  are  pain  in  the  breasts  due  to  the  intimate  sympathetic 
connection  of  the  mammee  with  the  gravid  uterus;  and  intense  inter- 
costal neuralgia,  which  a  careless  observer  might  mistake  for  pleu- 
ritic or  inflammatory  pain.  The  thermometer,  by  showing  that  there 
is  no  elevation  of  temperature,  Avould  prevent  such  a  mistake.  Neu- 
ralgia of  the  uterus  itself,  or  severe  pains  in  the  groins  or  thighs — 
the  latter  being  probably  the  mechanical  results  of  dragging  on  the 
attachments  of  the  abdominal  muscles — are  also  far  from  uncommon. 
In  the  treatment  of  such  neuralgic  affections  attention  to  the  state  of 
the  general  health,  and  large  doses  of  quinine  and  ferruginous  pre- 
parations whenever  there  is  much  debility,  will  be  indicated.  Locally 
sedative  applications,  such  as  belladonna  and  chloroform  liniments; 
friction  with  aconite  liniment  when  the  pain  is  limited  to  a  small 
space ;  and,  in  the  worst  cases,  the  subcutaneous  injection  of  mor- 
phia, will  be  called  for.  Those  pains  which  apparently  depend  on 
mechanical  causes  may  often  be  best  relieved  by  lessening  the  trac- 
tion on  the  muscles,  by  wearing  a  well-made  elastic  belt  to  support 
the  uterus. 

Paralysis  depending  on  Pregnancy. — Among  the  most  interesting 
of  the  nervous  diseases  are  various  paralytic  affections.  Almost  all 
varieties  of  paralysis  have  been  observed,  such  as  paraplegia,  hemi- 
plegia (complete  or  incomplete),  facial  paralysis,  and  paralysis  of  the 
nerves  of  special  sense,  giving  rise  to  amaurosis,  deafness,  and  loss  of 
taste.  Churchill  records  22  cases  of  paralysis  during  pregnancy, 
collected  by  him  from  various  sources.  A  large  number  have  also 
been  brought  together  by  Imbert  Goubeyre,^  in  an  interesting  memoir 
on  the  subject,  and  others  are  recorded  by  Fordyce  Barker,  Joulin, 
and  other  authors ;  so  that  there  can  be  no  doubt  of  the  fact  that 
paralytic  affections  are  common  during  gestation.  In  a  large  propor- 
tion of  the  cases  recorded  the  paralyses  have  been  associated  with 
albuminuria,  and  are  doubtless  ursemic  in  origin.  Thus  in  19  cases, 
related  by  Goubeyre,  albuminuria  was  present  in  all;  Darcy,^  how- 
ever, found  no  albuminuria  in  5  out  of  14  cases.    The  dependency  of 

1  Mem.  cle  I'Acad.  de  Med.,  1801.  2  These  de  Paris,  1877. 


DISEASES    OF    PREGNANCY.  203 

the  paralysis  on  a  transient  cause,  explains  tlio  fact  that  in  the  large 
majority  of  these  cases  the  paralysis  was  not  permanent,  but  disap- 
peared shortly  after  labor.  In  every  case  of  paralysis,  whatever  be 
its  nature,  special  attention  should  be  directed  to  the  state  of  the 
urine,  and,  should  it  be  found  to  be  albuminous,  labor  should  be  at 
once  induced.  This  is  clearly  the  proper  course  to  pursue,  and  we 
should  certainly  not  be  justified  in  running  the  risk  that  must  attend 
the  progress  of  a  case  in  which  so  formidable  a  symptom  has  already 
developed  itself.  When  the  cause  has  been  removed,  the  effect  will 
also  generally  rapidly  disappear,  and  the  prognosis  is  therefore,  on 
the  whole,  favorable.  Should  the  paralysis  continue  after  delivery, 
the  treatment  must  be  such  as  we  would  adopt  in  the  non-pregnant 
state;  and  small  doses  of  strychnia,  along  with  faradization  of  the 
affected  limbs,  would  be  the  best  remedy  at  our  disposal. 

Paralyses  tvhich  are  not  Ursemic  in  their  Oriyin. — There  are,  how- 
ever, unquestionably  some  cases  of  puerperal  paralysis  which  are  not 
uraemic  in  their  origin,  and  the  nature  of  which  is  somewhat  obscure. 
Hemiplegia  may  doubtless  be  occasioned  by  cerebral  hemorrhage,  as 
in  the  non-pregnant  state.  Other  organic  causes  of  paralysis,  such 
as  cerebral  congestion,  or  embolism,  may,  now  and  again,  be  met 
with  during  pregnane}',  but  cases  of  this  kind  must  be  of  compara- 
tive rarity.  Other  cases  are  functional  in  their  origin.  Tarnier 
relates  a  case  of  hemiplegia  which  he  could  only  refer  to  extreme 
anaemia.  Some,  again,  may  be  hysterical.  Paraplegia  is  apparently 
more  frequently  unconnected  with  albuminuria  than  the  other  forms 
of  paralysis;  and  it  may  either  depend  on  pressure  of  the  gravid 
uterus  on  the  nerves  as  they  pass  through  the  pelvis,  or  on  reflex 
action,  as  is  sometimes  observed  in  connection  with  uterine  disease. 
When,  in  such  cases,  the  absence  of  albuminuria  is  ascertained  by 
frequent  examination  of  the  urine,  there  is  obviously  not  the  same 
risk  to  the  patient  as  in  cases  depending  on  uraemia,  and  therefore  it 
may  be  justifiable  to  allow  pregnancy  to  go  on  to  term,  trusting  to 
subsequent  general  treatment  to  remove  the  paralytic  symptoms. 
As  the  loss  of  power  here  depends  on  a  transient  cause,  a  favorable 
prognosis  is  quite  justifiable.  Partial  paralysis  of  one  lower  ex- 
tremity, generally  the  left,  sometimes  occurs,  from  pressure  of  the 
foetal  occiput,  and  may  continue  for  some  days  or  weeks,  with  a 
gradual  improvement,  after  parturition. 

Chorea  is  not  infrequently  observed,  and  forms  a  serious  complica- 
tion. It  is  generally  met  with  in  young  women  of  delicate  health, 
and  in  the  first  pregnancy.  In  a  large  proportion  of  the  cases  the 
patient  has  already  suffered  from  the  disease  before  marriage.  On 
the  occurrence  of  pregnancy,  the  disposition  to  the  disease  again 
becomes  evoked,  and  choreic  movements  are  re-established.  This 
fact  may  be  explained  partly  by  the  susceptible  state  of  the  nervous 
system,  partly  by  the  impoverished  condition  of  the  blood. 

Prognosis. — That  chorea  is  a  dangerous  complication  of  pregnancy 
is  apparent  by  the  fact  that  out  of  56  cases  collected  by  Dr.  Barnes,^ 

'  Obst.  Trans.,  vol.  x. 


204  PREGNANCY. 

no  less  than  17,  or  1  in  3,  proved  fatal.  Nor  is  it  danger  to  life  alone 
that  is  to  be  feared,  for  it  appears  certain  that  chorea  is  more  apt  to 
leave  permanent  mental  disturbance  when  it  occurs  during  pregnancy, 
than  at  other  times.  It  has  also  an  unquestionable  tendency  to  bring 
on  abortion  or  premature  labor,  and  in  most  cases  the  life  of  the 
child  is  sacrificed. 

Treatment. — The  treatment  of  chorea  during  pregnancy  does  not 
difier  from  that  of  the  disease  under  more  ordinary  circumstances; 
and  our  chief  reliance  will  be  placed  on  such  drugs  as  the  liquor 
arsenicalis,  bromide  of  potassium,  and  iron.  In  the  severe  form,  of 
the  disease,  the  incessant  movements,  and  the  weariness  and  loss  of 
sleep,  may  very  seriously  imperil  the  life  of  the  patient,  and  more 
prompt  and  radical  measures  will  be  indicated.  If,  in  spite  of  our 
remedies,  the  paroxysms  go  on  increasing  in  severity,  and  the 
patient's  strength  appears  to  be  exhausted,  our  only  resource  is  to 
remove  the  most  evident  cause  by  inducing  labor.  Generally  the 
symptoms  lessen  and  disappear  soon  after  this  is  done.  There  can 
be  no  question  that  the  operation  is  perfectly  justifiable,  and  may 
even  be  essential  under  such  circumstances.  It  should  be  borne  in 
mind  that  the  chorea  often  recurs  in  a  subsequent  pregnancy,  and 
extra  care  should  then  always  be  taken  to  prevent  its  development. 

Disorders  of  the  urinary  organs  are  of  frequent  occurrence.  Ke- 
tention  of  urine  may  be  met  with,  and  this  is  often  the  result  of  a 
retroverted  uterus.  The  treatment,  therefore,  must  then  be  directed 
to  the  removal  of  the  cause.  This  subject  will  be  more  particularly 
considered  when  we  come  to  discuss  that  form  of  displacement  (p. 
209);  but  we  ma}^  here  point  out  that  retention  of  urine,  if  long  con- 
tinued, may  not  only  lead  to  much  distress,  but  to  actual  disease  of 
the  coats  of  the  bladder.  Several  cases  have  been  recorded  in  which 
cystitis,  resulting  from  urinary  retention  in  pregnancy,  eventually 
caused  the  exfoliation  of  the  entire  mucous  membrane  of  the  blad- 
der,^ which  was  cast  off,  sometimes  entire,  sometimes  in  shreds,  and 
occasionally  with  portions  of  the  muscular  coat  attached  to  it.  The 
possibility  of  this  formidable  accident  should  teach  us  to  be  caref-.il 
not  to  allow  any  undue  retention  of  urine,  but,  by  a  timely  use  of 
the  catheter,  to  relieve  the  symptoms,  while  we,  at  the  same  time, 
endeavor  to  remove  the  cause. 

Irritahility  of  the  bladder  is  of  frequent  occurrence.  In  the  early 
months  it  seems  to  be  the  consequence  of  sympathetic  irritation  of 
the  neck  of  the  bladder,  combined  with  pressure,  while  in  the  later 
months  it  is,  probably,  solely  produced  by  mechanical  causes.  When 
severe  it  leads  to  much  distress,  the  patient's  rest  being  broken,  and 
disturbed  by  incessant  calls  to  micturate,  and  the  suffering  induced 
may  produce  serious  constitutional  disturbances.  I  have  elscAvhere 
pointed  out,^  that  irritability  of  the  bladder  in  the  latter  months  of 
pregnancy  is  frequently  associated  with  an  abnormal  position  of  the 
foetus,  which  is  placed  transversely  or  obliquely.  The  result  is  either 
that  undue  pressure  is  applied  to  the  bladder,  or  that  it  is  drawn  out 

'  Obst.  Trans.,  vol.  xi.  2  Obst.  Trans.,  vol.  xiii. 


DISEASES    OF    PREGNANCY.  205 

of  its  proper  position.  The  abnormal  position  of  the  fo?tus  can  readily 
be  detected  by  palpation,  and  as  readily  altered  by  external  manipu- 
lation. In  some  of  the  cases  I  have  recorded,  altering  the  position 
of  the  foetus  was  immediately  followed  by  relief;  the  symptoms  re- 
curring after  a  time,  when  the  foetus  had  again  assumed  an  oblique 
position.  Should  the  foetus  frequently  become  displaced,  an  endeavor 
may  be  made  to  retain  it  in  the  longitudinal  axis  of  the  uterus  by  a 
proper  adaptation  of  bandages  or  pads.  In  cases  not  referable  to  this 
cause  we  should  attempt  to  relieve  the  bladder  symptoms  by  appro- 
priate medication,  such  as  small  doses  of  liquor  potass^,  if  the  urine 
be  very  acid  ;  tincture  of  belladonna  ;  the  decoction  of  triticum  repens, 
an  old  but  very  serviceable  remedy ;  and  vaginal  sedative  pessaries 
containing  morphia  or  atropine. 

[In  one  case  where  a  lady  had  borne  two  children  with  very  little 
inconvenience,  I  found  great  suffering  from  the  pressure  of  the  foetus 
on  the  bladder,  commencing  as  early  as  the  fifth  month.  This  con- 
tinued for  a  period  of  two  months,  when  she  very  fortunately  mis- 
carried. In  making  a  digital  exploration,  I  recognized  that  the 
foetus  was  anencephalus,  and  for  this  reason  descended  too  low  in  the 
pelvis. — ^Ed.] 

Incontinence  of  Urine.- — -Women  who  have  borne  many  children 
are  often  troubled  with  incontinence  of  urine  during  pregnancy,  the 
water  dribbling  away  on  the  slightest  movement.  Through  this 
much  irritation  of  the  skin  surrounding  the  genitals  is  produced,  at- 
tended with  troublesome  excoriations  and  eruptions.  Relief  may  be 
partially  obtained  by  lessening  the  pressure  on  the  bladder  by  an 
abdominal  belt,  while  the  skin  is  protected  by  applications  of  simple 
ointment  or  glycerine. 

Phosphatic  Deposit. — Dr.  Tyler  Smith  has  directed  attention  to  a 
phosphatic  condition  of  the  urine  occurring  in  delicate  women,  whose 
constitutions  are  severely  tried  by  gestation.  This  condition  can 
easily  be  altered  by  rest,  nutritious  diet,  and  a  course  of  restorative 
medicines,  such  as  steel,  mineral  acids,  and  the  like. 

Leucorrlicea. — A  profuse  whitish  leucorrhoeal  discharge  is  very 
common  during  pregnancy,  especially  in  its  latter  half.  The  discharge 
frequently  alarms  the  patient,  but,  unless  it  is  attended  with  disa- 
greeable symptoms,  it  does  not  call  for  special  treatment.  When  at 
all  excessive,  it  may  lead  to  much  irritation  of  the  vagina  and  ex- 
ternal generative  organs.  The  labia  may  become  excoriated  and 
covered  with  small  aphthous  patches,  and  the  whole  vulva  may  be 
hot,  swollen,  and  tender.  Warty  growths,  similar  in  appearance  to 
syphilitic  condylomata,  are  occasionally  developed  in  pregnant  women, 
unconnected  with  any  specific  laint,  and  associated  with'the  presence 
of  an  irritating  leucorrhoeal  discharge.  According  to  Thibi^rge,^ 
these  resist  local  applications,  such  as  sulphate  of  copper  or  nitrate 
of  silver,  but  spontaneously  disappear  after  delivery.  Inasmuch  as 
the  leucorrhceal  discharge  is  dependent  on  the  congested  condition  of 
the  generative  organs  accompanying  pregnancy,  we  can  hope  to  do 

'  Arch.  Gen.  de  Med.,  ^.856. 


206  PREGNANCY. 

little  more  than  alleviate  it.  In  the  severer  forms,  as  has  been  pointed 
out  bj  Henry  Bennet,  the  cervix  will  be  found  to  be  abraded  or 
covered  with  granular  erosion,  and  it  may  be,  from  time  to  time, 
cautiously  touched  with  the  nitrate  of  silver,  or  a  solution  of  carbolic 
acid.  Generally  speaking,  we  must  content  ourselves  Avith  recom- 
mending the  patient  to  wash  the  vagina  out  gently  with  diluted 
Condy's  fluid ;  or  with  a  solution  of  the  sulpho-carbolate  of  zinc,  of 
the  strength  of  four  grains  to  the  ounce  of  water  ;  or  with  plain  tepid 
water.  For  obvious  reasons  frequent  and  strong  vaginal  douches  are 
to  be  avoided,  but  a  daily  gentle  injection,  for  the  purpose  of  ablution, 
can  do  no  harm. 

Pruritis. — A  very  distressing  pruritis  of  the  vulva  is  frequently 
met  with  along  with  leucorrhoea,  especially  when  the  discharge  is  of 
an  acrid  character,  which  in  some  cases  leads  to  intense  and  protracted 
suffering,  forcing  the  patient  to  resort  to  incessant  friction  of  the  parts. 
Pruritis,  however,  may  exist  Avithout  leucorrhoea,  being  apparently 
sometimes  of  a  neuralgic  character,  at  others  associated  with  aphthous 
patches  on  the  mucous  membrane,  ascarides  in  the  rectum,  or  pediculi 
in  the  hairs  of  the  mons  veneris  and  labia.  Cases  are  even  recorded 
in  which  the  pruritic  irritation  extended  over  the  whole  body.  The 
treatment  is  difficult  and  unsatisfactory.  Various  sedative  applica- 
tions may  be  tried,  such  as  weak  solutions  of  Groulard's  lotion ;  or  a 
lotion  composed  of  an  ounce  of  the  solution  of  the  muriate  of  morphia, 
with  a  drachm  and  a  half  of  hydrocyanic  acid,  in  six  ounces  of  water  ; 
or  one  formed  by  mixing  one  part  of  chloroform  with  six  of  almond 
oil.  A  very  useful  form  of  medication  consists  in  the  insertion  into 
the  vagina  of  a  pledget  of  cotton-wool,  soaked  in  equal  parts  of  the 
glj^cerine  of  borax  and  sulphurous  acid.  This  may  be  inserted  at 
bedtime,  and  withdrawn  in  the  morning  by  means  of  a  string  attached 
to  it.  In  the  more  obstinate  cases,  the  solid  nitrate  of  silver  may  be 
lightly  brushed  over  the  vulva ;  or,  as  recommended  by  Tarnier,  a 
solution  of  bichloride  of  mercury,  of  about  the  strength  of  two  grs. 
to  the  ounce,  may  be  applied  night  and  morning.  The  state  of  the 
digestive  organs  should  always  be  attended  to,  and  aperient  mineral 
water  may  be  usefully  administered.  When  the  pruritis  extends 
beyond  the  vulva,  or  even  in  severe  local  cases,  large  closes  of  bromide 
of  potassium  may  perhaps  be  useful  in  lessening  the  general  hyper- 
aesthetic  state  of  the  nerves. 

Effects  of  Pressure.— ^omQ  of  the  disorders  of  pregnancy  are  the 
direct  results  of  the  mechanical  pressure  of  the  gravid  uterus.  _  The 
most  common  of  these  are  oedema  and  a  varicose  state  of  the  veins  ot 
the  lower  extremities,  or  even  of  the  vulva.  The  former  is  of  little 
consequence,  provided  we  have  assured  ourselves  that  it  is  really  the 
result  of  pressure,  and  not  of  albuminuria,  and  it  can  generally  be 
relieved  by  rest  in  the  horizontal  position.  A  varicose  state  of  the 
veins  of  the  lower  limbs  is  very  common,  especially  in  multiparse,  in 
whom  it  is  apt  to  continue  after  delivery.  Occasionally  the  veins  of 
the  vulva,  and  even  of  the  vagina,  are  also  enlarged  and  varicose, 
producing  considerable  swelling  of  the  external  genitals.  Eest  in 
the  recumbent  position,  and  the  use  of  an  abdominal  belt,  so  as  to 


DISEASES    OF    PREGNANCY.  207 

take  tlie  pressure  off  the  veins  as  much  as  possible,  arc  all  that  can 
be  done  to  relieve  this  troublesome  complication.  If  the  veins  of  the 
legs  are  much  swollen,  some  benefit  may  be  derived  from  an  elastic 
stoclcing  or  a  carefully  applied  bandage. 

Occasional  serious  results  from  Laceration  of  the  Veins. — Serious  and 
even  fatal  consequences  have  followed  the  accidental  laceration  of 
the  swollen  veins.  When  laceration  occurs  during  or  immediately 
after  delivery — a  not  uncommon  result  of  the  pressure  of  the  head — 
it  gives  rise  to  the  formation  of  a  vaginal  thrombus.  It  has  occa- 
sionally happened  from  an  accidental  injury  daring  pregnancy,  as  in 
the  cases  recorded  by  Simpson,  in  which  death  followed  a  kick  on 
the  pudenda,  producing  laceration  of  a  varicose  vein,  or  in  one  men- 
tioned by  Tarnier,  where  the  patient  fell  on  the  edge  of  a  chair. 
Severe  hemorrhage  has  followed  tlie  accidental  rupture  of  a  vein  in 
the  leg.  The  only  satisfactory  treatment  is  pressure,  applied  directly 
to  the  bleeding  parts  by  means  of  the  finger,  or  by  compresses  satu- 
rated in  a  solution  of  the  perchloride  of  iron.  The  treatment  of 
vaginal  thrombus  following  labor  must  be  considered  elsewhere. 
Occasionally  the  varicose  veins  inflame,  become  very  tender  and 
painful,  and  coagula  form  in  their  canals.  In  such  cases  absolute 
rest  should  be  insisted  on,  while  sedative  lotions,  such  as  the  chloro- 
form and  belladonna  liniments,  should  be  applied  to  relieve  the  pain. 

Displacements  of  the  Gravid  Uterus. — Certain  displacements  of  the 
gravid  uterus  are  met  with,  which  may  give  rise  to  symptoms  of 
great  gravity. 

Prolapse.^  which  is  rare,  is  almost  always  the  result  of  pregnancy 
occurring  in  a  uterus  which  had  been  previously  more  or  less  proci- 
dent.  Under  such  circumstances  the  increasing  weight  of  the  uterus 
will  at  first  necessarily  augment  the  previously  existing  tendency  to 
protrusion  of  the  womb,  which  may  come  to  protrude  partially  or 
entirely  beyond  the  vulva.  In  the  great  majority  of  cases,  as  preg- 
nancy advances,  the  prolapsus  cures  itself,  for  at  about  the  fourth  or 
fifth  month  the  uterus  will  rise  above  the  pelvic  brim.  It  has  been 
said,  that,  in  some  cases  of  complete  procidentia,  pregnancy  has  gone 
on  even  to  term,  with  the  uterus  lying  entirely  outside  the  vulva. 
Most  probably  these  cases  were  imperfectly  observed,  the  greater 
part  of  the  uterus  being  in  reality  above  the  pelvic  brim,  a  portion 
only  of  its  lower  segment  protruding  externally  ;  or,  as  has  some- 
times been  the  case,  the  protruding  portion  has  been  an  old  standing 
hypertrophic  elongation  of  the  cervix,  the  internal  os  uteri  and  fundus 
being  normally  situated.  Should  a  prolapsed  uterus  not  rise  into 
the  abdominal  cavity  as  pregnancy  advances,  serious  symptoms  will 
be  apt  to  develop  themselves ;  for,  unless  the  pelvis  be  unusually 
capacious,  the  enlarging  uterus  will  get  jammed  within  its  bony 
walls,  the  rectum  and  urethra  will  be  pressed  upon,  defecation  and 
micturition  will  be  consequently  impeded,  and  severe  pain  and  much 
irritation  will  result.  In  all  probability  such  a  state  of  things  would 
lead  to  abortion.  The  possibility  of  these  consequences  should,  there- 
fore, teach  us  to  be  careful  in  the  management  of  every  case  of  prolap- 
sus, however  slight,  in  which  pregnancy  occurs.     Absolute  rest,  in  the 


208  PREGNANCY. 

horizontal  position,  should  be  insisted  on  ;  while  the  uterus  should 
be  supported  in  the  pelvis  by  a  full-sized  Hodge's  pessary,  which 
should  be  worn  until  at  least  the  sixth  month,  when  the  uterus  would 
be  fully  within  the  abdominal  cavity.  After  delivery,  prolonged 
rest  should  be  recommended,  in  the  hope  that  the  process  of  involu- 
tion may  be  accompanied  by  a  cure  of  the  prolapse.  There  can  be 
no  doubt  that  pregnancy  carried  to  term  affords  an  opportunity  of 
curing  even  old-standing  displacements,  which  should  not  be  neg- 
lected. 

Anteversion  of  the  gravid  tderus  seldom  produces  symptoms  of 
consequence.  In  all  probability  it  is  common  enough  when  preg- 
nancy occurs  in  a  uterus  which  is  more  than  usually  anteverted,  or 
is  anteflexed.  Under  such  circumstances,  there  is  not  the  same  risk 
of  incarceration  in  the  pelvic  cavity  as  in  cases  in  which  pregnancy 
exists  in  a  retroflexed  uterus,  for,  as  the  uterus  increases  in  size,  it 
rises  without  difficulty  into  the  abdominal  cavity.  In  the  early 
months  the  pressure  of  the  fundus  on  the  bladder  may  account  for 
the  irritability  of  that  viscus  then  so  commonly  observed.  It  will 
be  remembered  that  Graily  Hewitt  attributes  great  importance  to 
this  condition  as  explaining  the  sickness  of  pregnancy — a  theory, 
however,  which  has  not  met  with  general  acceptation. 

Extreme  anteversion  of  the  uterus^  at  an  advanced  period  of  preg- 
nancy, is  sometimes  observed  in  multiparse  with  very  lax  abdominal 
walls,  occasionally  to  such  an  extent  that  the  uterus  falls  completely 
forwards  and  downwards,  so  that  the  fundus  is  almost  on  a  level 
with  the  patient's  knees.  This  form  of  pendulous  belly  may  be 
associated  with  a  separation  of  the  recti  muscles,  between  which  the 
womb  forms  a  ventral  hernia,  covered  only  by  the  cutaneous  textures. 
When  labor  comes  on  this  variety  of  displacement  may  give  rise  to 
trouble  by  destroying  the  proper  relation  of  the  uterine  and  pelvic 
axes.  The  treatment  is  purely  mechanical,  keeping  the  patient  l,ying 
on  her  back  as  much  as  possible,  and  supporting  the  pendulous  abdo- 
men by  a  properly  adjusted  bandage.  A  similar  forward  displace- 
ment is  observed  in  cases  of  pelvic  deformity,  and  in  the  worst  forms, 
in  rachitic  and  dwarfed  women,  it  exists  to  a  very  exaggerated  de- 
gree. 

Retroversion. — The  most  important  of  the  displacements,  in  conse- 
quence of  its  occasional  very  serious  results,  is  retroversion  of  the 
gravid  uterus.  It  was  formerly  generally  believed  that  this  w^as 
most  commonly  produced  by  some  accident,  such  as  a  fall,  which 
dislocated  a  uterus  previously  in  a  normal  position.  Undue  dis- 
tension of  the  bladder  was  also  considered  to  have  an  important 
influence  in  its  production,  by  pressing  the  uterus  backwards  and 
downwards. 

Its  Causes.- — It  is  now  almost  universally  admitted  that,  although 
the  above-named  causes  may  possibly  sometimes  produce  it,  in  the 
very  large  proportion  of  cases  it  depends  on  pregnancy  having 
occurred  in  a  uterus  previously  retroverted  or  retroflexed.  The 
merit  of  pointing  out  this  fact  unquestionably  belongs  to  the  late 


DISEASES    OF    PREGNANCY.  209 

Dr.  Tjler  Smith,  and  further  observations  have  fully  corroborated 
the  correctness  of  his  views. 

In  the  large  majority  of  cases  in  which  pregnancy  occurs  in  a 
uterus  so  displaced,  as  the  womb  enlarges,  it  straightens  itself,  and 
rises  into  the  abdominal  cavity,  without  giving  any  particular 
trouble;  or,  as  not  infrequently  happens,  the  abnormal  position  of 
the  organ  interferes  so  much  with  its  enlargement  as  to  produce 
abortion.  Sometimes,  however,  the  uterus  increases  without  leaving 
the  pelvis  until  the  third  or  fourth  month,  when  it  can  no  longer  be 
retained  in  the  pelvic  cavity  without  inconvenience.  It  then  presses 
on  the  urethra  and  rectum,  and  eventually  becomes  completely  in- 
carcerated within  the  rigid  walls  of  the  bony  pelvis,  giving  rise  to 
characteristic  symptoms. 

Sym2:)toms. — ^The  first  sign  which  attracts  attention  is  generally 
some  trouble  connected  with  micturition,  in  consequence  of  pressure 
on  the  urethra.  On  examination,  the  bladder  will  often  be  found  to 
be  enormously  distended,  forming  a  large,  fluctuating  abdominal 
tumor,  which  the  patient  has  lost  all  power  of  emptying.  Fre- 
quently small  quantities  of  urine  dribble  away,  leading  the  woman 
to  believe  that  she  has  passed  water,  and  thus  the  distension  is  often 
overlooked.  Sometimes  the  obstruction  to  the  discharge  of  urine  is 
so  great  as  to  lead  to  dropsical  effusion  into  the  cellular  tissue  of  the 
arms  and  legs.  This  was  very  well  marked  in  one  of  my  cases,  and 
disappeared  rapidly  after  the  bladder  had  been  emptied.  Difficulty 
in  defecation,  tenesmus,  obstinate  constipation,  and  inability  to  empty 
the  bowels,  becomes  established  about  the  same  time.  These  symp- 
toms increase,  accompanied  by  some  pelvic  pain  and  a  sense  of  weight 
and  bearing  down,  until  at  last  the  patient  applies  for  advice,  and 
the  true  nature  of  the  case  is  detected.  When  the  retroversion 
occurs  suddenly,  all  these  symptoms  develop  with  great  rapidity 
and  are  sometimes  very  serious  from  the  first. 

Progress  and  Ternunation.  —  The  further  progress  is  various. 
Sometimes,  after  the  uterus  has  been  incarcerated  in  the  pelvis  for 
more  or  less  time,  it  may  spontaneouslj^  rise  into  the  abdominal 
cavity,  when  all  threatening  symptoms  will  disappear.  So  happy  a 
termination  is  quite  exceptional,  and  if  the  practitioner  should  not 
interfere  and  effect  reposition  of  the  organ,  serious  and  even  fatal 
consequences  may  ensue,  unless  abortion  occurs. 

Termination  if  Reduction  is  not  Effected. — The  extreme  distension 
of  the  bladder,  and  the  impossibility  of  relieving  it,  may  lead  to 
lacerations  of  its  coats,  and  fatal  peritonitis;  or  the  retention  of  urine 
may  produce  cystitis,  with  exfoliation  of  the  coats  of  the  bladder; 
or,  as  more  commonly  happens,  retention  of  urinary  elements  may 
take  place,  and  death  occur  with  all  the  symptoms  of  urjemic  poison- 
ing. At  other  times  the  impacted  uterus  becomes  congested  and 
inflamed,  and  eventually  sloughs,  its  contents,  if  the  patient  survive, 
being  discharged  by  fistulous  communications  into  the  rectum  and 
vagina.  It  need  hardly  be  said  that  such  terminations  are  only  possi- 
ble in  cases  which  have  been  grossly  mismanaged,  or  the  nature  of 
which  has  not  been  detected  till  a  late  period. 


210  PREGNANCY. 

Diagnosis. — The  diagnosis  is  not  difficult.  On  making  a  vaginal 
examination,  the  finger  impinges  on  a  smooth  rounded  elastic  swell- 
ing, filling  up  the  lower  part  of  the  pelvis,  and  stretching  and  de- 
pressing the  posterior  vaginal  wall,  which  occasionally  protrudes 
beyond  the  vulva.  On  passing  the  finger  forwards  and  upwards  we 
shall  generally  be  able  to  reach  the  cervix,  high  up  behind  the  pubes, 
and  pressing  on  the  urethral  canal.  In  verj^  complete  retroversion 
it  may  be  difficult  or  impossible  to  reach  the  cervix  at  all.  On  ab- 
dominal examination  the  fundus  uteri  cannot  be  felt  above  the  pelvic 
brim ;  this,  as  the  retroversion  does  not  give  rise  to  serious  symp- 
toms until  between  the  third  and  fourth  months,  should,  under 
natural  circumstances,  always  be  possible.  By  bi- manual  examina- 
tion we  can  make  out,  with  due  care,  the  alternate  relaxation  and 
contraction  of  the  uterine  parietes  characteristic  of  the  gravid  uterus, 
and  so  differentiate  the  swelling  from  ^any  other  in  the  same  situa- 
tion. The  accompanying  phenomena  of  pregnancy  will  also  prevent 
any  mistake  of  this  kind. 

Retroversion  going  on  to  Term. — In  some  few  cases  retroversion  has 
been  supposed  to  go  on  to  term.  Strictly  speaking,  this  is  impossi- 
ble; but  in  the  supposed  examples,  such  as  in  the  well-known  case 
recorded  by  Oldham,  part  of  a  retroflexed  uterus  remained  in  the 
pelvic  cavity,  while  the  greater  part  developed  in  the  abdominal 
cavity.  The  uterus  is,  therefore,  divided,  as  it  were,  into  two  por- 
tions; one,  which  is  the  flexed  fundus,  remaining  in  the  pelvis,  the 
other,  containing  the  greater  part  of  the  foetus,  rising  above  it. 
Under  these  circumstances,  a  tumor  in  the  vagina  would  exist  in 
combination  with  an  abdominal  tumor,  and  pregnancy  might  go  on 
to  term.  Considerable  difficulty  maj^  even  arise  in  labor,  but  the 
malposition  generally  rectifies  itself  before  it  gives  rise  to  any  serious 
results. 

Treatment.- — The  treatment  of  retroversion  of  the  gravid  uterus 
should  be  taken  in  hand  as  soon  as  possible,  for  every  day's  delay 
involves  an  increase  in  the  size  of  the  uterus,  and,  therefore,  greater 
difficulty  in  reposition.  Our  object  is  to  restore  the  natural  direc- 
tion of  the  uterus,  by  lifting  the  fundus  above  the  promontory  of  the 
sacrum.  The  first  thing  to  be  done  is  to  relieve  the  patient  by  emp- 
tying the  bladder,  the  retention  of  urine  having  probably  originally 
called  attention  to  the  case.  For  this  purpose  it  is  essential  to  use  a 
long  elastic  male  catheter  of  small  size,  as  the  urethra  is  too  elon- 
gated and  compressed  to  admit  of  the  passage  of  the  ordinary  silver 
instrument.  Even  then  it  may  be  extremely  difficult  to  introduce 
the  catheter,  and  sometimes  it  has  been  found  to  be  quite  impossible. 
Under  such  circumstances,  provided  reposition  cannot  be  effected 
without  it,  the  bladder  may  be  punctured  an  inch  or  two  above  the 
pubes  by  means  of  the  fine  needle  of  an  aspirator,  and  the  urine 
drawn  off.  Dieulafoy's  work  on  aspiration  proves  conclusively  that 
this  may  be  done  without  risk,  and  the  operation  has  been  successfully 
performed  by  Schatz  and  others.  It  very  rarely  happens,  however, 
and  in  long-neglected  cases  only,  that  the  withdrawal  of  the  urine  is 
found  to  be  impossible. 


DISEASES    OF    PREGNANCY.  211 

Ifode  of  Effectiny  Reduction. — The  bladder  being  emptied,  and  the 
bowels  being  also  opened,  if  possible,  by  copious  eneraata,  we  pro- 
ceed, to  attempt  reduction.  For  this  purpose  various  procedures  are 
adopted.  If  the  case  is  not  of  very  long  standing,  I  am  inclined  to 
think  that  the  gentlest  and  safest  plan  is  the  continuous  pressure  of 
a  caoutchouc  bag,  filled  with  water,  placed  in  the  vagina.  Tlie  good 
effects  of  steady  and  long-continued  pressure  of  this  kind  were 
proved  by  Tyler  Smith,  who  effected  in  this  way  the  reduction  of  an 
invertediiterus  of  long  standing,  and  it  is  not  difficult  to  understand 
that  it  may  succeed  when  a  more  sudden  and  violent  effort  fails.  I 
have  tried  this  plan  successfully  in  two  cases,  a  pyriform  India-rub- 
ber bag  being  inserted  into  the  vagina,  and  distended  as  far  as  the 
patient  could  bear  by  means  of  a  syringe.  Tlie  water  must  be  let 
out  occasionally  to  allow  the  patient  to  empty  the  bladder,  and  the 
bag  immediately  refilled.  In  both  my  cases  reposition  occurred 
within  twenty-four  hours.  Barnes  has  failed  with  this  method  ;  but 
it  succeeded  so  well  in  ray  cases,  and  is  so  obviously  less  likely  to 
prove  hurtful  than  forcible  reposition  with  the  hand,  that  [  am  in- 
clined to  consider  it  the  preferable  procedure,  and  one  that  should  be 
tried  first.  Failing  with  the  fluid  pressure,  we  should  endeavor  to 
replace  the  uterus  in  the  following  way.  The  patient  should  be 
placed  at  the  edge  of  the  bed,  in  the  ordinary  obstetric  position,  and 
thoroughly  anaasthetized.  This  is  of  importance,  as  it  relaxes  all  the 
parts,  and  admits  of  much  freer  manipulation  than  is  otherwise  pos- 
sible. One  or  more  fingers  of  the  left  hand  are  then  inserted  into 
the  rectum  ;  if  the  patient  be  deeply  chloroformed,  it  is  quite  possi- 
ble, with  due  care,  even  to  pass  the  whole  hand,  and  an  attempt  is 
then  made  to  lift  or  push  the  fundus  above  the  promontory  of  the 
sacrum.  At  the  same  time  reposition  is  aided  by  drawing  down  the 
cervix  with  the  fingers  of  the  right  hand  per  vaginam.  It  has  been 
insisted  that  the  pressure  should  be  made  in  the  direction  of  one  or 
other  sacro-iliac  synchondrosis  rather  than  directly  upwards,  so  that 
the  uterus  may  not  be  Jammed  against  the  projection  of  the  promon- 
tory of  the  sacrum.  Failing  reposition  through  the  rectum,  an  at- 
tempt may  be  made  per  vaginam,  and  for  this  some  have  advised  the 
upward  pressure  of  the  closed  fist  passed  into  the  canal.  Others  recom- 
mend the  hand  and  position  as  facilitating  reposition,  but  this  pre- 
vents the  administration  of  chloroform,  which  is  of  more  assistance 
than  any  change  of  position  can  possibly  be.  Various  complex  in- 
struments have  been  invented  to  facilitate  the  operation,  but  they  are 
all  more  or  less  dangerous,  and  are  unlikely  to  succeed  when  manual 
pressure  has  failed. 

As  soon  as  the  reduction  is  accomplished,  subsequent  descent  of 
the  uterus  should  be  prevented  by  a  large-sized  Hodge's  pessary,  and 
the  patient  should  be  kept  at  rest  for  some  days,  the  state  of  the 
bladder  and  bowels  being  particularly  attended  to.  When  reposi- 
tion has  been  fairly  effected,  a  relapse  is  unlikely  to  occur. 

Treatment  when  Reduction  is  found  Impossible. — In  cases  in  which 
reduction  is  found  to  be  impossible,  our  only  resource  is  the  artificial 
induction  of  abortion.      Under  such  circumstances  this  is  impera- 


212  PREGNANCY. 

tivelj  called  for.  It  is  best  effected  by  puncturing  the  membranes, 
the  discharge  of  the  liquor  amnii  of  itself  lessening  the  size  of  the 
uterus,  and  thus  diminishing  the  pressure  to  which  the  neighboring 
parts  are  subjected.  After  this  reposition  may  be  possible,  or  we 
wait  until  the  foetus  is  spontaneously  expelled.  It  is  not  always  easy 
to  reach  the  os  uteri,  although  we  can  generally  do  so  with  a  curved 
uterine  sound.  If  we  cannot  puncture  the  membranes,  the  liquor 
amnii  may  be  drawn  off'  through  the  uterine  walls  by  means  of  the 
aspirator,  inserted  through  either  the  rectum  or  vagina.  The  injury 
to  the  uterine  walls  thus  inflicted  is  not  likely  to  be  hurtful,  and  the 
risk  is  certainly  far  less  than  leaving  the  case  alone.  Naturally  so 
extreme  a  measure  would  not  be  adopted  until  all  the  simpler  means 
indicated  have  been  tried  and  failed. 

Diseases  coexisting  with  Pregnancy . — ^The  pregnant  woman  is,  of 
course,  liable  to  contract  the  same  diseases  as  in  the  non-pregnant 
state,  and  pregnancy  may  occur  in  women  already  the  subject  of 
some  constitutional  disease.  There  is  no  doubt  yet  much  to  be 
learned  as  to  the  intluence  of  coexisting  disease  on  pregnancy.  It  is 
certain  that  some  diseases  are  but  little  modified  by  pregnancy,  and 
that  others  are  so  to  a  considerable  extent  ;  and  that  the  influence 
of  the  diseaee  on  the  foetus  varies  much.  The  subject  is  too  exten- 
sive to  be  entered  into  at  any  length,  but  a  few  words  may  be  said 
as  to  some  of  the  more  important  affections  that  are  likely  to  be  met 
with. 

Eruptive  Fevers.  Smalljoox. — The  eruptive  fevers  have  often  very 
serious  consequences,  proportionate  to  the  intensity  of  the  attack. 
Of  these  variola  has  the  most  disastrous  results,  which  are  related  in 
the  writings  of  the  older  authors,  but  which  are,  fortunately,  rarely 
seen  in  these  days  of  vaccination.  The  severe  and  confluent  forms 
of  the  disease  are  almost  certainly  fatal  to  both  the  mother  and  child. 
In  the  discrete  form,  and  in  modified  smallpox  after  vaccination,  the 
patient  generally  has  the  disease  favorably,  and,  although  abortion 
frequently  results,  it  does  not  necessarily  do  so. 

Scarlet  Fever. — If  scarlet  fever  of  an  intense  character  attacks  a 
pregnant  woman,  abortion  is  likely  to  occur,  and  the  risks  to  the 
mother  are  very  great.  The  milder  cases  run  their  course  without 
the  production  of  any  untoward  symptoms.  Should  abortion  occur, 
the  well-known  dangerous  effect  of  this  zymotic  disease  after  delivery 
will  gravely  influence  the  prognosis.  Cazeaux  was  of  opinion  that 
pregnant  women  are  not  apt  to  contract  the  disease ;  while  Mont- 
gomery thought  that  the  poison  when  absorbed  during  pregnancy 
might  remain  latent  until  delivery,  when  its  characteristic  effects 
were  produced. 

Measles^  unless  very  severe,  often  runs  its  course  without  seriously 
affecting  the  mother  or  child.  I  have  myself  seen  several  examples 
of  this.  De  Tourcoing,  however,  states  that  out  of  15  cases  the 
mother  aborted  in  7,  these  being  all  very  severe  attacks.  Some 
cases  are  recorded  in  which  the  child  was  born  with  the  rubeolous 
eruption  upon  it. 


DISEASES    OF    PREGNANCY.  213 

Continued  Fevers. — The  pregnant  woman  may  be  attaeked  with 
any  of  the  continued  fevers,  and,  if  they  are  at  all  severe,  they  are 
apt  to  produce  abortion.  Out  of  22  cases  of  typhoid,  16  aborted, 
and  the  remaining  6,  who  had  slight  attacks,  went  on  to  term ;  out 
of  63  cases  of  relapsing  fever,  abortion  or  premature  labor  occurred 
in  23.  According  to  Schweden  the  main  cause  of  danger  to  the 
foetus  in  continued  fevers  is  the  hyperpyrexia,  especially  when  the 
maternal  temperature  reaches  104"  or  upwards.  The  fevers  do  not 
appear  to  be  aggravated  as  regards  the  mother,  and  the  same  ob- 
servation has  been  made  by  Cazeaux  with  regard  to  this  class  of 
disease  occurring  after  delivery. 

Pneumonia  seems  to  be  specially  dangerous,  for  of  15  cases  collected 
by  Grisolle^  11  died — a  mortality  immensely  greater  tlian  that  of  the 
disease  in  general.  The  larger  proportion  also  aborted,  the  children 
being  generally  dead,  and  the  fatal  result  is  probably  due,  as  in  the 
severe  continued  fevers,  to  hyperpyrexia.  The  cause  of  the  maternal 
mortality  does  not  seem  quite  apparent,  since  the  same  danger  does 
not  appear  to  exist  in  severe  bronchitis,  or  other  inflammatory 
affections. 

Phthisis. — Contrary  to  the  usually  received  opinion  it  appears 
certain  that  pregnancy  had  no  retarding  influence  on  coexisting 
phthisis,  nor  does  the  disease  necessarily  advance  with  greater 
rapidity  after  delivery.  Out  of  27  cases  of  phthisis,  collected  by 
Grisolle,^  24  showed  the  first  symptoms  of  the  disease  after  pregnancy 
had  commenced.  Phthisical  women  are  not  apt  to  conceive  ;  a  fact 
wdiich  may  probably  be  explained  by  the  freqnent  coexistence,  in 
such  cases,  of  uterine  disease,  especially  severe  leucorrhoea.  The 
entire  duration  of  the  phthisis  seems  to  be  shortened,  as  it  averaged 
only  nine  and  a  half  months  in  the  27  cases  collected — a  fact  which 
proves,  at  least,  that  pregnancy  has  no  material  influence  in  arresting 
its  progress.  If  we  consider  the  tax  on  the  vital  powers  which 
pregnancy  naturally  involves,  we  must  admit  that  this  view  is  more 
physiologically  probable  than  the  one  generally  received,  and  appa- 
rently adopted  without  any  due  grounds. 

Heart-disease. — The  evil  effects  of  pregnancy  and  parturition  on 
chronic  heart-disease  have  of  late  received  much  attention  from 
Speigelberg,  Fritsch,  Peter,  and  other  writers.  The  subject  has  been 
ably  discussed^  in  a  series  of  elaborate  papers  by  Dr.  Angus  Mac- 
Donald,  which  are  well  worthy  of  study.  Out  of  28  cases  collected 
by  him,  17,  or  60  per  cent.,  proved  fatal.  This,  no  doubt,  is  not 
altogether  a  reliable  estimate  of  the  probable  risk  of  the  complica- 
tion ;  but,  at  any  rate,  it  shows  the  serious  anxiety  which  the  occur- 
rence of  pregnancy  in  a  patient  suffering  from  chronic  heart-disease 
must  cause.  Dr.  MacDonald  refers  the  evils  resulting  from  pregnancy 
in  connection  with  cardiac  lesions  to  two  causes  :  First,  destruction 
of  that  equilibrium  of  the  circulation,  which  has  been  established 

'  Arch.  Gen.  de  M^rl.  vol.  xiii.  p.  298.  2  l\,i^,  vol.  xxii. 

3  Obstet.  Journ.  1877. 


21-4  PREGNANCY. 

by  compensatory  arrangements ;  secondly,  the  occurrence  of  fresh 
inflammatory  lesions  upon  the  valves  of  the  heart  already  diseased. 

The  dangerous  symptoms  do  not  usually  appear  until  after  the 
first  half  of  the  pregnancy  has  passed,  and  the  pregnancy  seldom 
advances  to  term.  The  pathological  phenomena  generally  met  with 
in  fatal  cases  are  pulmonary  congestion,  especially  of  the  bronchial 
mucous  membrane,  and  pulmonary  oedema,  with  occasional  pneu- 
monia and  pleurisy.  Mitral  stenosis  seems  to  be  the  form  of  cardiac 
lesion  most  likely  to  prove  serious,  and  next  to  this  aortic  incompe- 
tency. The  obvious  deduction  from  these  facts  is  that  heart-disease, 
especially  when  associated  with  serious  symptoms,  such  as  dyspnoea, 
palpitation,  and  the  like,  should  be  considered  a  strong  contra-indica- 
tion  of  marriage.  When  pregnane}^  has  actually  occurred,  all  that 
can  be  done  is  to  enjoin  the  careful  regulation  of  the  life  of  the 
patient,  so  as  to  avoid  exj)osure  to  cold,  and  all  forms  of  severe 
exertion. 

Syphilis. — The  important  influence  of  syphilis  on  the  ovum  is  fully 
considered  elsewhere.  As  regards  the  mother,  its  effects  are  not 
different  from  those  at  other  times.  It  need  only,  therefore,  be  said 
that,  whenever  indications  of  syphilis  in  a  pregnant  woman  exist, 
the  appropriate  treatment  should  be  at  once  instituted  and  carried 
on  during  her  gestation,  not  only  with  the  view  of  checking  the  pro- 
gress of  the  disease,  but  in  the  hope  of  preventing  or  lessening  the 
risk  of  abortion,  or  of  the  birth  of  an  infected  infant.  So  far  from 
pregnancy  contra- indicating  mercurial  treatment,  there  rather  is  a 
reason  for  insisting  on  it  more  strongly.  As  to  the  precise  medica- 
tion, it  is  advisable  to  choose  a  form  that  can  be  exhibited  continu- 
ously for  a  length  of  time  without  producing  serious  constitutional 
results.  Small  doses  of  the  bichloride  of  mercury,  such  as  one-six- 
teenth of  a  grain,  thrice  daily,  or  of  the  iodide  of  mercury,  answer  this 
purpose  well;  or,  in  the  early  stages  of  pregnancy,  the  mercurial 
vapor  bath,  or  cutaneous  inunction,  may  be  employed. 

Dr.  Weber,  of  St.  Petersburg,^  has  made  some  observations  show- 
ing the  superiority  of  the  latter  methods,  which  he  found  did  not 
interfere  with  the  course  of  pregnancy ;  the  contrary  was  the  case 
when  the  mercury  was  administered  by  the  mouth,  probably,  as  he 
supposes,  from  disturbance  of  the  digestive  system.  It  must  be  borne 
in  mind,  that  in  married  women  it  may  sometimes  be  expedient  to 
prescribe  an  anti-syphilitic  course  without  their  knowledge  of  its 
nature,  so  that  inunction  is  not  always  feasible. 

Epilepsy. — The  influence  of  pregnancy  on  epilepsy  does  not  appear 
to  be  as  uniform  as  might  perhaps  be  expected.  In  some  cases  the 
number  and  intensity  of  the  fits  have  been  lessened,  in  others  the 
disease  becomes  aggravated.  Some  cases  are  even  recorded  in  which 
epilepsy  appeared  for  the  first  time  during  gestation.  On  account 
of  the  resemblance  between  epilepsy  and  eclampsia  there  is  a  natural 
apprehension  that  a  pregnant  epileptic  may  suffer  from  convulsions 

1  Allgem.  Med.  Cent.  Zeit.  Feb.  1875. 


DISEASES    OF    PREGNANCY.  215 

during  delivery.  Fortunately,  this  is  by  no  means  necessaril}^  the 
case,  and  labor  often  goes  on  satisfactorily  without  any  attaclv. 

Jaundice^  the  result  of  acute  yellow  atrophy  of  the  liver,  is  occa- 
sionally observed,  and  is  said  to  have  been  sometimes  epidemic. 
Independently  of  the  grave  risks  to  the  mother,  it  is  most  likely  to 
produce  abortion  or  the  death  of  the  foetus.  According  to  Davidson, 
it  originates  in  catarrhal  icterus,  the  excretion  of  the  bile-products 
being  impeded  in  consequence  of  pregnancy,  and  their  retention 
giving  rise  to  the  foetal  blood-poisoning  which  accompanies  the 
severer  forms  of  the  disease.  Slight  and  transient  attacks  of  jaun- 
dice may  occur,  without  being  accompanied  by  any  bad  consequences. 
Tlieir  production  is  probably  favored  by  the  mechanical  pressure  of 
the  gravid  uterus  on  the  intestines  and  the  bile-ducts. 

Carcinoma. — The  occcurrence  of  pregnancy  in  a  woman  suffering 
from  malignant  disease  of  the  uterus  is  by  no  means  so  rare  as 
might  be  supposed,  and  must  naturally  give  rise  to  much  anxiety  as 
to  the  result.  The  obstetrical  treatment  of  these  cases  will  be  dis- 
cussed elsewhere.  Should  we  be  aware  of  the  existence  of  the  dis- 
ease during  gestation,  the  question  will  arise  whether  we  should  not 
attempt  to  lessen  the  risks  of  delivery  by  bringing  on  abortion  or 
premature  labor.  The  question  is  one  which  is  by  no  means  easy  to 
settle.  We  have  to  deal  with  a  disease  which  is  certain  to  prove 
fatal  to  the  mother  before  long,  and  the  progress  of  which  is  proba- 
bly accelerated  after  labor,  while  the  manipulations  necessary  to  in- 
duce delivery  may  very  unfavorably  influence  the  diseased  structures. 
Again,  by  such  a  measure  we  necessarily  sacrifice  the  child,  while 
we  are  by  no  means  certain  that  we  materially  lessen  the  danger  to 
the  mother.  The  question  cannot  be  settled  except  on  a  considera- 
tion of  each  particular  case.  If  we  see  the  patient  early  in  pregnancy, 
by  inducing  abortion  we  may  save  her  the  dangers  of  labor  at  term 
— possibly  of  the  Csesarean  section — if  the  obstruction  be  great. 
Under  such  circumstances,  the  operation  would  be  justifiable.  If  the 
pregnancy  have  advanced  beyond  the  sixth  or  seventh  month,  unless 
the  amount  of  malignant  deposit  be  very  small  indeed,  it  is  probable 
that  the  risks  of  labor  would  be  as  great  to  the  mother  as  a  term, 
and  it  would  then  be  advisable  to  give  her  the  advantage  of  the  few 
months'  delay. 

Ovarian  Tumor. — Cases  are  occasionally  met  with  in  which  preg- 
nancy occurs  in  women  who  are  suffering  from  ovarian  tumor,  and 
their  proper  management  has  given  rise  to  considerable  discussion. 
There  can  be  no  doubt  that  such  cases  are  attended  with  very  danger- 
ous and  often  fatal  consequences,  for  the  abdomen  cannot  well  ac- 
commodate the  gravid  uterus  and  the  ovarian  tumor,  both  increasing 
simultaneously.  The  result  is  that  the  tumor  is  subject  to  much 
contusion  and  pressure,  which  have  sometimes  led  to  the  rupture  of 
the  cyst,  and  the  escape  of  its  contents  into  the  peritoneal  cavity;  at 
others  to  a  low  form  of  inflammation,  attended  with  much  exhaustion, 
the  death  of  the  patient  supervening  either  before  or  shortly  after 
delivery.  The  danger  during  delivery  from  the  same  cause,  in  the 
cases  which  go  on  to  term,  is  also  very  great.     Of  13  cases  of  delivery 


216  PREGNANCY. 

by  the  natural  powers,  which  I  collected  in  a  paper  on  "Labor  Corn- 
plicated  with  Ovarian  Tamor,"^  far  more  than  one-half  proved  fatal. 
[In  one  instance  in  this  city,  a  lady  well  known  to  the  editor,  gave 
birth  to  three  of  her  four  children,  during  the  existence  of  an  ovarian 
tumor.  The  children  all  lived  to  grow  up,  and  their  mother  died  of 
her  disease  at  the  age  of  75,  after  being  repeatedly  tapped  daring 
fifty  years.  The  ovarian  tumor  was  discovered  by  Dr.  Benjamin 
Eush  soon  after  her  first  child  was  born  in  1809,  and  she  was  first 
tapped  by  Dr.  Physick  in  1811.  In  1812,  1815,  and  1818  she  gave 
birth  to  the  children  mentioned,  the  third  being  delicate,  sickly,  and 
weighing  six  pounds.  This  last  died  of  phthisis  when  45 ;  the  others 
still  live.^ — Ed.]  Another  source  of  danger  is  twisting  of  the  pedicle, 
and  consequent  strangulation  of  the  cyst,  of  which  several  instances 
are  recorded.  It  is  obvious,  then,  that  the  risks  are  so  manifold  that 
in  every  case  it  is  advisable  to  consider  whether  they  can  be  lessened 
by  surgical  treatment. 

Methods  of  Treatment. — The  means  at  our  disposal  are  either  to 
induce  labor  prematurely,  to  treat  the  tumor  by  tapping,  or  to  per- 
form ovariotomy.  The  question  has  been  particularly  discussed  by 
Spencer  Wells  in  his  works  on  "  Ovariotomy,"  and  by  Barnes  in  his 
"  Obstetric  Operations."  The  former  holds  that  the  proper  course  to 
pursue  is  to  tap  the  tumor  when  there  is  any  chance  of  its  being 
materiallv  lessened  in  size  by  that  procedure,  but  that  when  it  is 
mQltilocular,  or  when  its  contents  are  solid,  ovariotomy  should  be 
performed  at  as  early  a  period  of  pregnancy  as  possible.  Barnes,  on 
the  other  hand,  maintains  that  the  safer  course  is  to  imitate  the 
means  by  which  nature  often  meets  this  complication,  and  bring  on 
premature  labor  without  interfering  with  the  tumor.  He  thinks  that 
ovariotomy  is  out  of  the  question,  and  that  tapping  may  be  insuffi- 
cient and  leave  enough  of  tlie  tumor  to  interfere  seriously  with  labor. 
So  far  as  recorded  cases  go,  they  unquestionably  seem  to  show  that 
tapping  is  not  more  dangerous  than  at  other  times,  and  that  ovario- 
tomy may  be  practised  during  pregnancy  with  a  fair  amount  of  suc- 
cess. Wells  records  10  cases  which  were  surgically  interfered  with. 
In  1  tapping  was  performed,  and  in  9  ovariotomy ;  and  of  these  8 
recovered,  the  pregnancy  going  on  to  term  in  5.  On  the  other  hand, 
5  cases  were  left  alone,  and  either  went  to  term,  or  spontaneous  pre- 
mature labor  supervened ;  and  of  these  3  died.  The  cases  are  not 
sufficiently  numerous  to  settle  the  question,  but  they  certainly  favor 
the  view  taken  by  Wells  rather  than  that  by  Barnes.  It  is  to  be 
observed  that,  unless  we  give  up  all  hope  of  saving  the  child,  and 
induce  abortion,  the  risk  of  induced  premature  labor,  when  the  preg- 
nancy is  sufficiently  advanced  to  hope  for  a  viable  child,  would  almost 
be  as  great  as  that  of  labor  at  term  ;  for  the  question  of  interference 
will  only  have  to  be  considered  with  regard  to  large  tumors,  which 
would  be  nearly  as  much  affected  by  the  pressure  of  a  gravid  uterus 
at  seven  or  eight  mouths,  as  by  one  at  term.     Small  tumors,  gene- 

'  Obst.  Trans.,  vol.  ix. 

[2  Trans.  Pliila.  Obstet.  Soc.  vol.  i.  1873,  p.  64.— reported  by  Ed.] 


DISEASES    OP    PREGNANCY.  217 

rally  escape  attention,  and  are  more  apt  to  be  impacted  before  the 
presenting  part  in  delivery.  The  success  of  ovariotomy  during 
pregnancy  bus  certainly  been  great,  and  we  have  to  bear  in  mind 
that  the  woman  must  necessarily  be  subjected  to  the  risk  of  the 
operation  sooner  or  later,  so  that  we  cannot  judge  of  the  case  as  one 
in  which  abortion  terminates  the  risk.  Even  it  the  operation  should 
put  an  end  to  the  pi'cgnancy — and  there  is  at  least  a  fair  chance  that 
it  will  not  do  so — there  is  no  certainty  that  that  would  increase  the 
risk  of  the  operation  to  the  mother,  while  as  regards  the  child  we 
should  only  have  the  same  result  as  if  we  intentionally  produced 
abortion.  On  the  whole,  then,  it  seems  that  the  best  change  to  the 
mother,  and  certainly  the  best  to  the  child,  is  to  resort  to  tlie  appa- 
rently heroic  practice  recommended  by  Wells.  The  determination 
must,  however,  be  to  some  extent  influenced  by  the  skill  and  ex- 
perience of  the  operator.  If  the  medical  attendant  has  not  gained 
that  experience  which  is  so  essential  for  a  successful  ovariotomist, 
the  interests  of  the  mother  would  be  best  consulted  by  the  induction 
of  abortion  at  as  early  a  period  as  possible.  One  or  other  procedure, 
is  essential ;  for,  in  spite  of  a  few  cases  in  which  several  successive 
pregnancies  have  occurred  in  women  who  have  had  ovarian  tumors, 
the  risks  are  such  as  not  to  justify  an  expectant  practice.  Should 
rupture  of  the  cyst  occur,  there  can  be  no  doubt  that  ovariotomy 
should  at  once  be  resorted  to,  with  the  view  of  removing  the  lacerated 
cyst  and  its  extravasated  contents. 

Fibroid  Tumors. — Pregnancy  may  occur  in  a  uterus  in  which  there 
are  one  or  more  fibroid  tumors.  If  these  are  situated  low  down  and 
in  a  position  likely  to  obstruct  the  passage  of  the  foetus,  they  may 
very  seriously  complicate  delivery.  When  they  are  situated  in  the 
fundus  or  body  of  the  uterus  they  may  give  rise  to  risk  from  hemor- 
rhage, or  from  inflammation  of  their  own  structure.  Inasmuch  as 
they  are  structurally  similar  to  the  uterine  walls  they  partake  of  the 
growth  of  the  uterus  during  pregnancy,  and  frequently  increase  re- 
markably in  size.  Cazeaux  says — •"  I  have  known  them  in  several 
instances  to  acquire  a  size  in  three  or  four  months  which  they  would 
not  have  done  in  several  years  in  the  non-pregnant  condition."  Con- 
versely, they  share  in  the  involution  of  the  uterus  after  delivery,  and 
often  lessen  greatly  in  size,  or  even  entirely  disappear.  Of  this  fact  I 
have  elsewhere  recorded  several  curious  examples  ;^  and  many  other 
instances  of  the  complete  disappearance  of  even  large  tumors  have 
been  described  by  authors  whose  accuracy  of  observation  cannot  be 
questioned. 

Treatment. — The  treatment  will  vary  with  the  position  of  the 
tumor.  If  it  is  such  as  to  be  certain  to  obstruct  the  passage  of  the 
child,  abortion  should  be  induced  as  soon  as  possible.  If  the  tumor 
is  well  out  of  the  way,  this  is  not  so  urgently  called  for.  The  princi- 
pal danger  then  is  that  the  tumor  will  impede  the  post-mortem  con- 
traction of  the  uterus,  and  favor  hemorrhage.  Even  if  this  should 
happen,  the  flooding  could  be  controlled  by  the  usual  means,  espe- 

'  Obst.  Trans,  vols.  v.  xiii.  and  xix. 
15 


218  PREGNANCY, 

cially  by  the  injection  of  the  perchloride  of  iron.  I  have  seen  several 
cases  in  which  delivery  has  taken  place  under  such  circumstances 
without  any  untoward  accident.  The  danger  from  inflammation  and 
subsequent  extrusion  of  the  fibroid  masses  would  probably  be  as 
great  after  abortion  or  premature  labor,  as  after  delivery  at  term.  It 
seems,  therefore,  to  be  the  proper  rule  to  interfere  when  the  tumors 
are  likely  to  impede  delivery,  and  in  other  cases  to  allow  the  preg- 
nancy to  go  on,  and  be  prepared  to  cope  with  any  complications  as 
they  arise.  The  risks  of  pregnancy  should  be  avoided  in  every  case 
in  which  uterine  fibroids  of  any  size  exist,  the  patients  being  advised 
to  lead  a  celibate  life. 


CHAPTER   IX. 

PATHOLOGY  OF  THE  DECIDUA  AND  OVUM. 

CoMPAEATiVELY  little  is,  unfortunately,  known  of  the  pathological 
changes  which  occur  in  the  mucous  membrane  of  the  uterus  during 
pregnancy.  It  is  probable  that  they  are  of  much  more  consequence 
than  is  generally  believed  to  be  the  case ;  and  it  is  certain  that  they 
are  a  frequent  cause  of  abortion. 

Endom.etritis. — One  of  the  most  generall}^  observed  probably  de- 
pends on  endometritis  antecedent  to  conception.  When  the  impreg- 
nated ovule  reached  the  uterus,  it  engrafted  itself  on  the  inflamed 
mucous  membrane,  which  was  in  an  unfit  condition  for  its  reception 
and  growth.  A  not  uncommon  result,  under  such  circumstances,  is 
the  laceration  of  some  of  the  decidual  vessels,  extravasation  of  blood 
between  the  decidua  and  the  uterine  walls,  and  consequent  abortion 
at  an  early  stage  of  pregnancy.  As  this  morbid  state  of  the  uterine 
mucous  membrane  is  likely  to  continue  after  abortion  is  completed, 
the  same  history  repeats  itself  on  each  impregnation,  and  thus  we 
may  ^\r.'/o  constant  early  miscarriages  produced.  It  does  not  neces- 
sarily follow,  however,  that  the  pregnancy  is  immediately  terminated 
when  this  state  of  things  is  present.  Sometimes  a  condition  of 
hyperplasia  of  the  decidua  is  produced,  the  membrane  becomes  much 
thickened  and  hypertrophied,  and  the  decidual  cells  are  greatly  in- 
creased in  size  (Fig.  83).  In  other  instances  the  internal  surface  of 
the  decidua  becomes  studded  with  rough  polypoid  growths,^  depend- 
ing on  proliferation  of  its  interstitial  tissue.  Duncan  has  found  that 
the  hypertrophied  decidua  is  always  in  a  state  of  fatty  degeneration, 
more  advanced  in  some  places  than  in  others.^  The  result  of  these 
alterations  is  frequently  to  produce  dwindling  or  death  of  the  ovum, 

'  Virchow's  Archiv  fiir  Path.  1868.  2  Researches  in  Obstetrics,  p.  293. 


PATHOLOGY    OF    THE    DECIDUA    AND    OVUM. 


219 


which,  however,  retains  its  connection  with  the  decidua,  until,  after 
a  lapse  of  time,  the  decidua  is  expelled  in  the  form  of  a  thick  tri- 


FiG.  83. 


Hypertrophierl  Decidua  laid  open,  with  the  Ovum  attached  to  its  Fundal  Portion.     (After  Duncan.) 


angular  fleshy  substance,  with 
the  atrophied  ovum  attached  to 
some  part  of  its  inner  surface. 
In  Other  cases,  in  which  the 
hyperplasia  has  advanced  to  a 
less  extent,  the  nutrition  of  the 
foetus  i^  not  interfered  with, 
and  pregnancy  may  continue  to 
term,  the  changes  in  the  decidua 
being  recognizable  after  de- 
livery. Other  diseases  besides 
endometritis  may  give  rise  to 
similar  alterations  in  the  de- 
cidua, one  of  these  being  as 
Yirchow  maintains,  syphilis. 
The  converse  condition,  and  im- 
perfect development  of  the  de- 
cidua, especially  of  the  decidua 
reflexa,  has  also  been  noted  as 


Fig.  84. 


Imperfectly  developed  Decidua  Vera,  with  the 
Ovum.    (After  Duncan.) 


220  PKEGNANCY. 

a  cause  of  abortion.  The  ovum  will  then  Lang  loosely  in  the  ute- 
rine cavity,  without  the  support  which  the  growth  of  the  deciduare- 
flexa  around  it  ought  to  aftbrd,  and  its  premature  expulsion  readily 
follows  (Fig.  81). 

Hydrorrhoea  Gravidarum. — The  peculiar  condition  known  as  hy- 
drorrhcea  gravida7-uvi  most  probably  depends  on  some  obscure  morbid 
state  of  the  uterine  mucous  membrane.  By  this  is  meant  a  discharge 
of  clear  watery  fluid  at  intervals  during  piregnancy.  It  may  happen 
at  any  period  of  gestation,  but  is  most  commonly  met  with  in  the 
latter  months.  It  may  commence  with  a  mere  dribbling,  or  there 
may  be  a  sudden  and  copious  discharge  of  fluid.  Afterwards  the 
watery  fluid,  which  is  generally  of  a  pale  yellowish  color,  and  trans- 
parent like  the  liquor  amnii,  may  continue  to  escape  at  intervals  for 
many  weeks,  and  sometimes  in  very  great  abundance,  so  as  to  satu- 
rate the  patient's  clothes.  Very  frequently  it  is  expelled  in  gushes, 
and  at  night,  when  the  patient  is  lying  quietly  in  bed;  its  escape  is 
then  probably  due  to  uterine  contraction. 

Many  theories  liave  been  held  as  to  its  cause.  By  some  it  is 
attributed  to  the  rupture  of  a  cyst  placed  between  the  ovum  and  the 
uterine  walls  ;  Baudelocque  referred  it  to  a  transudation  of  the  hquor 
amnii  through  the  membranes;  while  Burgess  and  Dubois  believed 
it  to  depend  on  a  laceration  of  the  membranes  at  a  distance  from  the 
OS  uteri.  Mattel  more  recently  has  attributed  it  to  the  existence  of 
a  sac  between  the  chorion  and  the  amnion.  It  may  be  that  in  some 
instances  a  single  discharge  of  fluid  may  come  from  one  of  the  two 
last-mentioned  causes.  But  if  it  be  continuous  or  repeated,  another 
source  must  be  sought  for.  liegar'  maintains  that  it  is  the  result  of 
abundant  secretion  from  the  glands  of  the  mucous  membrane,  which 
accumulates  between  the  decidua  and  chorion,  and  escapes  through 
the  OS  uteri.  If  this  occur  the  decidua  is  probably  in  an  hypertro- 
phied  and  otherwise  morbid  state.  Hydrorrhoea  is  chiefly  of  interest 
from  the  error  of  diagnosis  it  is  likely  to  give  rise  to ;  for,  on  being 
summoned  to  a  case  in  which  watery  discharge  has  occurred  for  the 
first  time,  we  are  naturally  apt  to  suppose  that  the  membranes  have 
ruptured,  and  that  labor  is  imminent.  Nor  is  there  any  very  certain 
means  of  deciding  if  this  be  so.  In  hydrorrhoea,  we  find  that  pains 
are  absent,  the  os  uteri  unopened,  and  ballottement  may  be  made 
out.  Even  if  the  membranes  be  ruptured,  there  will  be  no  indica- 
tion for  interference  unless  labor  has  actually  commenced  ;  'and  the 
repetition  of  the  discharge,  and  the  continuance  of  the  pregnancy, 
will  soon  clear  up  the  diagnosis.  Hydrorrhoea,  although  apt  to 
alarm  the  patient,  need  not  give  rise  to  any  anxiety.  The  pregnancy 
generally  progresses  favorably  to  the  full  period;  although,  in  excep- 
tional cases,  premature  labor  may  supervene.  No  treatment  is  neces- 
sary, nor  is  there  any  that  could  have  the  least  effect  in  controlling 
the  discharge. 

Patholociy  of  the  Chorion.— 'Y\-\Q  only  important  disease  of_  the 
chorion,  with  which  we  are  acquainted,  is  the  well-known  condition 

'  Monat.  f.  Geburt.,  18G3. 


PATHOLOGY  OF  THE  DECIDUA  AND  OVUM. 


221 


Fig.  85. 


whicli  is  variously  described  as  uterine  hydatids,  cystic  disease  of  the 
ovum,  hydatiform  de'jeneration  of  the  chorion,  or  vesicular  mole.  The 
name  of  uterine  hydatids  was  long  given  to  it  on  the  supposition  that 
the  grapelike  vesicles,  which  characterize  the  disease,  were  true  hyda- 
tids, similar  to  those  which  develop  in  the  liver  and  other  structures. 
This  idea  has  long  been  exploded,  and  it  is  now  known  as  a  certainty 
that  the  disease  originates  in  the  villi  of  the  chorion.  The  precise 
mode  and  the  causes  of  its  production,  are,  however,  not  yet  satisfac- 
torily settled.  The  disease  is  character- 
ized by  the  existence  in  the  cavity  of  the 
uterus  of  a  large  number  of  translucent 
vesicles,  containing  a  clear  limpid  fluid, 
which  has  been  found  on  analysis  to  bear 
close  resemblance  to  the  liquor  amnii. 
These  small  bladder  like  bodies,  which 
vary  in  size  from  that  of  a  millet-seed  to 
an  acorn,  are  often  described  as  resem- 
bling a  bunch  of  grapes  or  currants.  On 
more  minute  examination,  they  are  found 
not  to  be  each  attached  to  independent 
pedicles,  as  is  the  case  in  a  banch  of 
grapes,  but  some  of  them  grow  from 
other  vesicles,  while  others  have  distinct 
pedicles  attached  to  the  chorion,  the  pedi- 
cles themselves  sometimes  being  dis- 
tended by  fluid  (Fig.  85).  This  peculiar 
arrangement  of  the  vesicles  is  explained 
by  their  mode  of  growth. 

Causes  of  Cystic  Degeneration. — There 
has  been  considerable  discussion  as  to 
the  etiology  of  this  disease.  By  some  it 
is  supposed  always  to  follow  death  of 
the  foetus  ;  and  the  whole  developmental 
energy  being  expended  on  the  chorion,  which  retains  its  attachment 
to  the  decidua,  the  result  is  its  abnormal  growth  and  cystic  degenera- 
tion. This  is  the  view  maintained  by  Gierse  and  Graily  Hewitt,  and 
it  is  favored  by  the  undoubted  fact  that  in  almost  all  cases  the  foetus 
has  entirely  disappeared ;  and  by  the  occasional  occurrence  of  cases 
of  twin  conceptions  in  which  one  chorion  has  degenerated,  the  other 
remaining  healthy  until  term.  On  the  other  hand,  it  is  maintained 
that  the  starting-point  is  connected  with  the  maternal  organism; 
Virchow  thinks  it  originates  in  a  morbid  state  of  the  decidua;  while 
others  have  attributed  it  to  some  blood  dyscrasia  on  the  part  of  the 
mother,  such  as  syphilis.  There  are  many  reasons  for  believing  that 
causes  of  this  nature  may  originate  the  affection.  Thus  it  is  often  found 
to  occur  more  than  once  in  the  same  person  ;  and  alterations  of  a  simi- 
lar kind,  although  limited  in  extent,  are  not  unfrequently  found  in 
connection  with  the  placenta  and  membranes  of  living  children.  On 
this  theory  the  death  of  the  foetus  is  secondary,  the  conscquetice  of 
impaired  nutrition  from  the  morbid  state  of  the  chorion.     The  prob- 


Hyilatit'orm  DegenevatioD  of  the 
Chorion. 


222  PREGNANCY. 

ability  is  that  both  views  may  be  right,  the  disease  sometimes  fol- 
lowing the  death  of  the  embryo,  and  at  others  being  tlie  result  of 
obscure  maternal  causes. 

Pathology. — The  degeneration  of  the  chorion  villi  generally  com- 
mences at  an  early  period  of  pregnancy,  before  the  placenta  has  com- 
menced to  form.  In  that  case  the  entire  superficies  of  the  chorion 
becomes  affected.  The  disease,  however,  may  not  begin  until  after 
the  greater  part  of  the  chorion  villi  has  atrophied,  and  then  it  is  lim- 
ited to  the  placenta.  The  epithelium  of  the  villi  appears  to  be  the 
part  first  aft'ected,  and  the  whole  interior  of  the  diseased  villus 
becomes  filled  with  cells.  The  connective  tissue  of  the  villus  under- 
goes a  remarkable  proliferation,  and  collects  in  masses  at  individual 
spots,  the  remainder  of  the  villus  being  unaffected.  By  the  growth 
of  these  elements  the  villus  becomes  distended,  and  many  of  the  cells 
liquefy,  the  intercellular  fluid,  thus  produced,  widely  separating  the 
connective  tissue,  so  as  to  form  a  network  in  the  interior  of  the  vil- 
lus.' Thus  are  formed  the  peculiar  grapelike  bodies  which  charac- 
terize the  disease.  When  once  the  degeneration  has  commenced,  the 
diseased  tissue  has  a  remarkable  power  of  increase,  so  that  it  some- 
times forms  a  mass  as  large  as  a  child's  head,  and  several  pounds  in 
weight. 

The  nutrition  of  the  altered  chorion  is  maintained  by  its  connec- 
tions with  the  decidua,  which  is  also  generally  diseased  and  hypertro- 
phied.  Sometimes  the  adhesion  of  the  mass  to  the  uterine  walls  is 
very  firm,  and  may  interfere  with  its  expulsion  ;  while,  in  a  few  rare 
cases,  it  has  been  found  that  the  villi  have  forced  their  way  into  the 
substance  of  the  uterus,  chiefly  through  the  uterine  sinuses,  and  thus 
caused  atrophy  and  thinning  of  its  muscular  structure.  Cases  of 
this  kind  are  related  by  Volkmann,  Waldeyer,^  and  Barnes,  and  it  is 
obvious  that  the  intimate  adhesion  thus  effected  must  seriously  add 
to  the  gravity  of  the  prognosis. 

Medico-leyal  Questions. — Taking  this  view  of  the  etiology  of  this 
disease,  it  is  obvious  that  it  is  essentially  connected  with  pregnancy, 
and  that  there  is  no  valid  ground  for  maintaining,  as  has  sometimes 
been  done,  that  it  ma}^  occur  independently  of  conception.  It  is  just 
possible,  however,  that  true  entozoa  may  form  in  the  substance  of 
the  uterus,  which  being  expelled  per  vaginam,  might  be  taken  for 
the  results  of  cystic  disease,  and  thus  give  rise  to  groundless  suspi- 
cions as  to  the  patient's  chastity.  Hewitt  has  related  one  case  in 
which  true  hydatids,  originally  formed  in  the  liver,  had  extended  to 
the  peritoneum,  and  were  about  to  burst  through  the  vagina  at  the 
time  of  death.  This  occurred  in  an  unmarried  woman.  One  or  two 
other  examples  of  true  hydatids  forming  in  the  substance  of  the  ute- 
rus are  also  recorded.  A  y^vj  interesting  case  is  also  related  by 
Hewitt,^  in  which  undoubted  acephalocysts  were  expelled  from  the 
uterus  of  a  patient  who  ultimately  recovered.     A  careful  examina- 

1  Braxton  Hicks,  Guy's  Hospital  Reports,  vol.  ii.     Third  Series,  p.  183. 

*  Virchow's  Archiv,  vol.  xliv.  p.  88. 

*  Obstet.  Transj,  vol.  xii. 


PATHOLOGY    OF    THE    DECIHUA    AND    OVUM.  223 

tion  of  the  cjst  and  its  contents  would  show  their  true  nature,  as  the 
echinococci  heads,  with  their  characteristic  hooklets,  would  be  dis- 
coverable by  the  microscope. 

It  is  also  possible  that  unfounded  suspicions  might  arise  from  the 
fact  of  a  patient  expelling  a  mass  of  hydatids  long  after  impregnation. 
In  the  case  of  a  widow,  or  woman  living  apart  from  her  husband, 
serious  mistakes  might  thus  be  made.  This  has  been  specially 
pointed  out  by  McClintock,^  who  says,  "Hydatids  may  be  retained  in 
utero  for  many  months  or  years,  or  a  portion  only  may  be  expelled, 
and  the  residue  may  throw  out  a  fresh  crop  of  vesicles,  to  be  dis- 
charged on  a  future  occasion."" 

Sym'pioms  and  Progress  of  the  Disease. — The  sj-mptoms  of  cystic 
disease  of  the  ovum  are  by  no  means  well  marked.  At  first  there  is 
nothing  to  point  to  the  existence  of  any  morbid  condition,  but  as 
pregnancy  advances  its  ordinary  course  is  interfered  with.  There  is 
more  general  disturbance  of  the  health,  than  there  ought  to  be,  and 
the  reflex  irritations,  such  as  vomiting,  may  be  unusually  developed. 
The  first  physical  sign  remarked  is  rapid  increase  of  the  uterine 
tumor,  which  soon  does  not  correspond  in  size  to  the  supposed  period 
of  pregnancy.  Thus,  at  the  third  month,  the  uterus  may  be  found 
to  reach  up  to,  or  beyond  the  umbilicus.  About  this  time  there 
generally  are  more  or  less  profuse  watery  and  sanguineous  dis- 
charges, which  have  been  described  as  resembling  currant  juice. 
They  no  doubt  depend  on  the  breaking  down  and  expulsion  of  the 
cysts,  caused  by  painless  uterine  contractions.  They  are  sometimes 
excessive  in  amount,  recur  with  great  frequencj^,  and  often  reduce 
the  patient  extremely.  Portions  of  cysts  may  now  generally  be  found 
mingled  with  the  discharge,  and  sometimes  large  masses  of  them  are 
expelled  from  time  to  time.  Indeed,  the  discovery  of  portions  of 
cysts  is  the  only  certain  diagnostic  sign.  Vaginal  examination, 
before  the  os  has  dilated,  will  give  no  information,  except  the  absence 
of  ballotternent.  An  unusual  hardness  or  density  of  the  uterus — • 
described  by  Leishman,  who  attributes  much  importance  to  it,  as  "a 
peculiar  doughy,  boggy  feeling" — has  been  pointed  out  by  several 
writers.  The  contour  of  the  uterine  tumor,  moreover,  is  often  irregu- 
lar. In  addition,  we,  of  course,  fail  to  discover  the  usual  ausculta- 
tory signs  of  pregnancy.  All  this  may  aid  in  diagnosis,  but  nothing, 
except  the  presence  of  cysts  in  the  watery  bloody  discharge,  will 
enable  us  to  pronounce  with  certainty  as  to  the  nature  of  the  disease. 

Treatment. — As  soon  as  the  diagnosis  is  established,  the  indications 
for  treatment  are  obvious.  The  sooner  the  uterus  is  cleared  of  its 
contents  the  better.  Ergot  may  be  given  with  advantage  to  favor 
uterine  contraction,  and  the  expulsion  of  the  diseased  ovum.  Should 
this  fail,  more  especially  if  the  hemorrhage  be  great,  the  fingers,  or 
the  whole  hand,  must  be  introduced  into  the  uterus,  and  as  much  as 
possible  of  the  mass  removed.  As  the  os  is  likely  to  be  closed,  its 
preliminary  dilatation  by  sponge  or  laminaria  tents,  or  by  a  Barnes's 
bag,  if  it  be  already  opened  to  some  extent,  will  in  most  cases  be 

'  McClintock's  Diseases  of  Women,  p.  398. 


22-1  PREGNANCY. 

required.  If  cbloroform  be  then  administered,  the  remaining  steps 
of  the  operation  will  be  easy.  On  account  of  the  occasional  firm 
adhesion  of  the  cystic  mass  to  the  uterus,  too  energetic  attempts  at 
complete  separation  should  be  avoided.  Any  severe  hemorrhage 
after  the  operation  can  be  controlled  by  swabbing  out  the  uterine 
cavity  with  the  perchloride  of  iron  solution. 

Under  the  name  of  Myxo'ma  fibros^tra^  a  more  rare  degeneration  of 
the  chorion  has  been  described  by  Virchow  and  Hildebrandt,^  char- 
acterized, not  by  vesicular,  but  fibroid  degeneration  of  the  connective 
tissue  of  the  chorion.  This  is,  however,  too  little  understood  to 
require  further  observation. 

Pathology  of  the  Placenta.- — The  pathology  of  the  placenta  has  of 
late  years  attracted  much  attention,  and  it  has  an  important  practical 
bearing  in  consequence  of  its  effects  on  the  child. 

Placentae  vary  considerably  in  shape.  They  may  be  crescentic,  or 
spread  over  a  considerable  surface,  in  consequence  of  the  chorion 
villi  entering  into  communication  with  a  larger  portion  of  the  de- 
cidua  than  usual  [Placenta  memhranacea).  Such  forms,  however, 
are  merely  of  scientific  interest.  The  only  anomaly  of  shape  of  any 
practical  importance  is  the  formation  of  what  have  been  called  pla- 
centse  succenturise.  These  consist  of  one  or  more  separate  masses  of 
placental  tissue,  produced  by  the  development  of  isolated  patches  of 
chorion  villi.  Hohl  believes  that  they  always  form  exactly  at  the 
junction  of  the  anterior  and  posterior  walls  of  the  uterus,  which  in 
early  pregnancy  is  a  mere  line.  As  the  uterus  expands,  the  portions 
of  placenta,  on  each  side  of  this,  become  separated  from  each  other. 
They  are  only  of  consequence  from  the  possibility  of  their  remain- 
ing unnoticed  in  the  uterus  after  delivery,  and  giving  rise  to  second- 
ary post-partum  hemorrhage.  The  rare  form  of  double  placenta 
with  a  single  cord,  figured  in  the  accompanying  woodcut  (Fig.  86), 
was  probably  formed  in  this  way,  and  the  supplementary  portion,  in 
such  a  case,  might  readily  escape  notice. 

The  placenta  may  also  vary  in  dimensions.  Sometimes  it  is  of 
excessive  size,  generally  when  the  child  is  unusually  big;  but  not 
infrequently  in  connection  with  hydramnios,  the  child  being  dead 
and  shrivelled.  In  other  cases  it  is  remarkably  small,  or  at  least 
appears  to  be  so.  If  the  child  be  healthy,  this  is  probably  of  no 
pathological  importance,  as  its  smallness  may  be  more  apparent  than 
real,  depending  on  its  vessels  not  being  distended  with  blood.  When 
true  atrophy  of  the  placenta  exists,  the  vitality  of  the  foetus  may  be 
seriously  interfered  with.  This  condition  may  depend  either  on  a 
diseased  state  of  the  chorion  villi,  or  of  the  decidua  in  which  they 
are  implanted.^  The  latter  is  the  more  common  of  the  two ;  and  it 
generally  consists  in  hyperplasia  of  the  connective  tissue  of  the  de- 
cidua, which  presses  on  the  villi  and  vessels,  and  gives  rise  to  gen- 
eral or  local  atrophy.  This  change  is  similar  in  its  nature  to  that 
observed  in  cirrhosis  of  the  liver,  and  certain  forms  of  Bright's  dis- 

'  Monat.  f.  Gehurt,  May,  1865. 

2  Wliittaker,   Araer.  Jouni.  of  Obst.,  vol.  iii.,  p.  229. 


PATHOLOGY    OF    THE    DECIDUA    AND    OVUM. 


225 


ease.  It  has  generally  been  ascribed  to  inflammatory  changes,  and, 
under  the  name  of  'placeniiiis^  Las  been  described  by  man}-  authors, 
and  has  been  considered  to  be  a  common  disease.  To  it  are  attributed 
many  of  the  morbid  alterations  which  are  commonly  observed  in 
placentae,  such  as  hepatizations,  circumscribed  purulent  deposits,  and 
adhesions  to  the  uterine  walls.  Many  modern  pathologists  have 
doubted  whether  these  changes  are  in  any  proper  sense  inflammatory. 
Whittaker  observes  on  this  point:  "The  disposition  to  reject  pla- 
centitis altogether  increases  in  modern  times.  Indeed,  it  is  impos- 
sible to  conceive  of  inflammation  on  the  modern  theory  (Cohnheim) 


Fig.  86. 


Double  Placenta,  witli  single  cord. 

of  that  process,  since  there  are  no  capillaries,  in  the  maternalportion 
at  least,  through  whose  walls  a  'migration'  might  occur,  and  there 
are  no  nerves  to  regulate  the  contractility  of  the  vessel-walls  in  the 
entire  structure."  .  Robin  thus  explains  the  various  pathological 
changes  above  alluded  to:  "What  has  been  taken  for  inflammation 
of  the  placenta  is  nothing  else  than  a  condition  of  transformation  of 
blood  clots  at  various  periods.  "What  has  been  regarded  as  pus  is 
only  fibrine  in  the  course  of  disorganization,  and  in  those  cases 
where  true  pus  has  been  found  the  pus  did  not  come  from  the  pla- 
centa, but  from  an  inflammation  of  the  tissue  of  the  uterine  vessels 
and  an  accidental  deposition  in  the  tissue  of  the  placenta."  The 
extravasations  of  blood  here  alluded  to  are  of  very  common  occur- 
rence, and  they  are  found  in  all  parts  of  the  organ ;  in  its  substance; 


226 


PREGNANCY. 


on  its  decidual  surface,  or  immediately  below  the  amnion,  wliere 
they  serve  as  points  of  origin  for  the  cysts  that  are  there  often 
observed.  The  fibrine  thus  deposited  undergoes  retrograde  meta- 
morphosis as  in  other  parts  of  the  body  ;  it  becomes  decolorized,  it 
undergoes  fatty  degeneration  or  becomes  changed  into  calcareous 
masses ;  and  in  this  way,  it  is  supposed,  may  be  explained  the  vari- 
ous pathological  changes  which  are  so  commonly  observed.  The 
amount  of  retrograde  metamorphosis,  and  the  precise  appearance 
presented  will,  of  course,  depend  on  the  time  that  has  elapsed  since 
the  blood  extravasations  toolv  place. 

Fatty  degeneration  of  the  placenta,  and  its  influence  on  the  nutri- 
tion of  the  foetus,  have  been  specially  studied  in  this  country  by 
Barnes  and  Druitt.  Yellowish  masses  of  varying  size  are  nq,yj  com- 
monly met  with  in  placentae,  and  these  are  found  to  consist,  in  great 


Fig.  87. 


Fatty  Degeneration  of  the  Placenta. 

part,  of  molecular  fat,  mixed  with  a  fine  network  of  fibrous  tissue. 
The  true  fatty  degeneration,  however,  specially  affects  the  chorion 
villi  (Fig.  87).  On  microscopic  examination  they  are  found  to  be 
altered  and  misshaped  in  their  contour,  and  to  be  loaded  with  fine 
granular  fat-globules.  Similar  changes  are  observed  in  the  cells  of 
the  decidua.  The  influence  on  the  foetus  will,  of  course,  depend  on 
the  extent  to  which  the  functions  of  the  villi  are  interfered  with. 
The  probable  cause  of  this  degeneration,  is,  no  doubt,  some  obscure 
alteration  in  the  nutrition  of  the  tissue,  depending  on  the  state  of  the 


PATHOLOGY    OF    THE    DECIDUA    AND    OVUM, 


227 


Fig.  88. 


mother's  health.  Barnes  believes  that  syphilis  has  much  influence 
in  its  production.  Druitt  has  pointed  out  that  some  amount  of  fatty 
degeneration  is  always  present  in  a  mature  placenta,  and  is  probaVjly 
connected  with  the  physiological  separation  of  the  organ ;  and  Good- 
ell  has  more  recently  suggested  that  an  unusual  amount  of  this  chano-e 
may  be  merely  an  anticipation  of  the  natural  termination  of  the  life 
of  the  placenta.^ 

Other  morbid  states  of  the  placenta,  of  greater  rarity,  are  occasion- 
ally met  with,  as  an  oedematous  infiltration  of  its  tissue,  always  occur- 
ring, according  to  Lange,  in  cases  of 
hydramnios;  pigmentary  and  calcareous 
deposits ;  and  tumors  of  various  kinds  ; 
but  these  require  only  a  passing  mention. 

Pathology  of  the  Cfinhilical  Cord. — The 
umbilical  cord  may  be  of  excessive  length, 
varying  from  18  to  20  inches,  which  is 
its  average  measurement,  up  to  50  or  60 
inches,  and  a  case  is  recorded  in  which  it 
even  reached  the  extraordinary  length  of 
9  feet.  If  unusually  long  it  may  be 
twisted  round  the  limbs  or  neck  of  the 
child,  and  the  latter  position  may,  in  ex- 
ceptional instances,  prove  injurious  dur- 
ing labor. 

Some  authors  refer  cases  of  spontane- 
ous amputation  of  foetal  limbs  in  utero 
to  constrictions  by  the  umbilical  cord, 
but  this  accident  is  more  probably  pro- 
duced by  filamentous  adnexa  of  the 
amnion.  Knots  in  the  cord  are  not  un- 
common, and  they  result  from  the  foetus, 
in  its  movements,  passing  through  a  loop  of  the  cord  (Fig.  88).  If 
there  is  an  average  amount  of  Wharton's  jelly  in  the  cord  the  ves- 
sels are  protected  from  pressure,  and  no  bad  effects  follow.  Gery,  in 
a  recent  paper  on  this  subject,^  attempts  to  show  that  such  knots"^  are 
more  important  than  is  generally  believed,  and  relates  two  cases  in 
which  he  believes  them  to  have  caused  the  death  of  the  foetus. 

Extreme  torsion  of  the  cord,  an  exaggeration  of  the  spiral  twists 
generally  observed,  may  prove  injurious,  and  even  fatal,  to  the  child 
by  obstructing  the  circulation  in  the  vessels.  Spaeth  mentions  three 
cases  in  which  this  caused  the  death  of  the  foetus,  the  cord  being 
twisted  until  it  was  reduced  to  the  thickness  of  a  thread. 

Anomalies  in  the  distribution  of  the  vessels  of  the  cord  are  of. 
common  occurrence.     The  cord  may  be  attached  to  the  edge,  instead 
of  to  the  centre,  of  the  placenta  {hattledore  placenta).     It  may  break 
up  into  its  component  parts  before  reaching  the  placenta,  the  vessels 
running  through  the  membranes ;  and  if,  in  such  a  case,  traction  on 


Knots  of  the  Umbilical  Cord. 


'  American  Journal  of  Obstetrics,  vol.  ii.  p.  535. 
2  L'Union  Medicale,  Oct.  1876, 


228  PREGNANCY. 

the  cord  be  made,  the  separate  vessels  may  lacerate,  and  the  cord  be- 
come detached.  There  may  be  two  veins  and  one  artery,  or  only 
one  vein  and  one  artery,  or  there  may  be  two  separate  cords  to  one 
placenta.  These,  and  other  anomalies  that  might  be  mentioned,  are 
of  little  practical  importance. 

The  principal  pathological  condition  of  the  amnion  with  which  we 
are  acquainted  is  that  which  is  associated  with  excessive  secretion  of 
liquor  amnii,  and  is  generally  known  under  the  name  oi  hydramnios^ 
which  term  Kidd^  limits  to  cases  in  which  more  than  two  quarts  of 
amniotic  fluid  exist.  Its  precise  cause  is  still  a  matter  of  doubt.  By 
some  it  is  referred  to  inflammation  of  the  amnion  itself;  at  other  times 
it  is  apparently  connected  with  some  morbid  state  of  the  decidua, 
which  may  be  found  diseased  and  hypertrophied.  The  foetus  is  very 
often  dead  and  shrivelled,  and  the  placenta  enlarged  and  oedematous. 
It  does  not  necessarily  folloAV,  however,  that  hydramnios  causes  the 
death  of  the  child.  Out  of  33  cases  McClincock  found  that  9  children 
were  born  dead  f  and  of  the  19  born  alive,  10  died  within  a  few  hours, 
the  remainder  survived.  Tliere  does  not  appear  to  be  any  marked 
relation  between  the  state  of  the  mother's  health  and  the  occurrence 
of  this  disease  ;  and  it  is  certainly  not  necessarily  present  when  the 
mother  is  suffering  from  dropsical  effusions  in  other  parts  of  the 
body.  The  theory  that  the  disease  is  of  purely  local  origin  is  favored 
by  the  fact,  that  when  hydramnios  occurs  in  twin  pregnancy,  one 
ovum  only  is  generally  affected.  Its  effects,  as  regards  the  mother, 
are  chiefly  mechanical.  It  rarely  begins  to  show  itself  before  the 
.fifth  or  sixth  month  of  pregnancy,  but,  when  once  it  has  commenced, 
it  rapidly  produces  a  feeling  of  discomfort  and  enlai'gement,  alto- 
gether beyond  that  Avhich  should  exist  at  the  period  of  pregnancy 
which  has  been  reached.  In  advanced  stages  the  distress  produced 
is  often  very  great,  the  enlarged  uterus  pressing  upon  the  diaphragm, 
and  producing  much  embarrassment  of  respiration.  Premature  ex- 
pulsion of  the  foetus  very  often  supervenes.  Four  out  of  McClintock's 
patients  died  after  labor,  showing  that  the  maternal  mortality  is 
high,  a  result  which  he  refers  to  the  debilitated  state  of  the  women 
who  were  the  subjects  of  the  disease. 

.  Diagnosis. — The  diagnosis  is  not,  as  a  rule,  difficult.  It  has  to  be 
distinguished  from  ascitic  distension  of  the  abdomen,  from  enlarge- 
ment of  the  uterus  from  twin  pregnancy,  and  from  ovarian  tumor,  or 
pregnancy  complicated  with  ovarian  tumor.  The  first  will  be  rec- 
ognized by  the  superficial  position  of  the  fluid  ;  the  difficulty  of  feel- 
ing the  contour  of  the  uterus,  which  is  obscured  by  the  surrounding 
fluid,  and  the  results  of  percussion  which  show  that  the  fluid  is  free 
in  the  peritoneal  cavity  ;  and  by  the  coexistence  of  dropsical  effusions 
in  other  parts  of  the  body.  The  second  may  be  difficult,  and  even 
impossible,  to  diagnose  from  it:  generall}^,  however,  in  hydramnios 
the  uterine  tumor  is  more  distinctly  tense  or  fluctuating  ;   the  foetal 

'  On  the  Diagnosis  of  Dropsy  of  the  Amnion.     Proceedings  of  the  Obstetrical  So- 
ciety of  Dublin,  May  11,  1878. 
*  Diseases  of  Women,  p.  383. 


PATHOLOGY    OF    THE    DECIDUA    AND    OVUM.  229 

limbs  cannot  be  felt  on  palpation ;  and  the  lower  segment  of  the 
uterus,  as  felt  per  vaginam,  is  unusually  distended,  the  presenting 
part  not  being  apprecialjle.  Ovarian  tumors  alone,  or  complicating 
pregnancy,  may  also  be  difficult  to  distinguish  from  dropsy  of  the 
amnion.  The  general  history  of  the  case,  and  the  presence  or  ab- 
sence of  signs  of  pregnancy,  may  enable  us  to  arrive  at  a  diagnosis  ; 
and  Kidd  points  out  that  the  position  of  the  uterus,  whether  gravid 
or  not,  is  usually  low  down  in  the  pelvis  in  ovarian  dropsy,  while  in 
dropsy  of  the  amnion  it  is  drawn  high  up,  and  reached  with  difficulty 
on  vaginal  examination. 

Its  effect  on  Labor. — During  labor  an  excessive  amount  of  liquor 
amnii  is  often  a  cause  of  deficient  uterine  action  and  delay,  the  pains 
being  feeble  and  ineffective.  This,  of  course,  tells  chiefly  in  the  first 
stage,  which  is  often  much  prolonged,  unless  the  membranes  are 
punctured  early,  and  the  superabundant  fluid  allowed  to  escape. 

Treatment. — No  treatment  is  known  to  have  any  effect  on  the 
disease.  If  the  discomfort  and  distension  are  very  great,  it  may  be 
absolutely  necessary  to  puncture  the  membranes,  and  allow  the  Avater 
to  escape.  This  inevitably  brings  on  labor.  If  the  pregnancy  be 
not  sufficiently  advancad  to  give  hope  for  the  birth  of  a  living  child, 
we  would  not,  of  course,  resort  to  this  expedient  unless  the  mother's 
health  was  seriously  imperilled.  It  is  possible  that  in  such  cases  the 
patient  might  be  relieved  by  inserting  the  minute  needle  of  an  aspi- 
rator through  the  os,  and  removing  a  certain  quantity  of  the  liquor 
amnii  by  aspiration,  without  inducing  the  labor.  I  have  never  had 
an  opportunity  of  trying  this  expedient,  but  it  seems  a  possibility. 

Deficiency  of  Liquor  Amni'. — A  defective  amount  of  liquor  amnii 
is  said  to  favor  certain  malformations,  by  allowing  the  uterus  to 
compress  the  foetus  unduly.  It  certainly  occasionally  gives  rise  to 
adhesion  between  the  fostus  and  the  membranes,  and  to  the  formation 
of  amniotic  bands  which  are  capable  of  producing  certain  fostal  de- 
formities (p.  227). 

Aiopearance  of  the  Liquor  Amnii. — The  liquor  amnii  itself  varies 
much  in  appearance,  It  is  sometimes  thick  and  treacly,  instead  of 
limpid,  and  it  may  be  offensive  in  odor.  The  cause  of  these  varia- 
tions is  not  well  understood. 

Patholo'jy  of  the  Foetus. — There  is  abundant  evidence  that  the  foetus 
in  utero  is  subject  to  many  diseases,  some  of  which  cause  its  death, 
and  others  leave  distinct  traces  of  their  existence,  although  not 
proving  fatal.  The  subject  is  of  great  importance,  and  is  v/ell  worthy 
of  study.  There  is  still  much  to  be  done  in  this  direction,  which 
may  lead  to  important  practical  results.  I  can,  however,  do  little 
more  than  enumerate  some  of  the  principal  affections  which  have 
been  observed. 

Blood  Diseases  transmitted  throufjh  the  Mother.  Smalli^x. — It  is  a 
well-established  fact  that  the  various  eruptive  fevers,  from  which 
the  mother  may  suffer,  may  be  communicated  to  the  foetus  in  utero. 
When  the  mother  is  attacked  with  confluent  smallpox,  she  almost 
always  aborts,  but  not  necessarily  so  when  it  is  discrete  or  modified. 
In  such  cases  it  has  often  happened  that  the  foetus  has  been  born 


230  PREGNANCY. 

witli  evident  marks  of  smallpox.  Cases  are  on  record  which  prove 
that  the  foetus  was  attacked  subsequently  to  the  mother.  Thus  a 
mother  attacked  with  smallpox  has  miscarried,  and  has  given  birth 
to  a  living  child  showing  no  trace  of  the  disease,  which,  however, 
showed  itself  in  two  or  three  days;  proving  that  it  had  been  con- 
tracted, and  had  run  through  its  usual  period  of  incubation,  when 
the  foetus  was  still  in  utero.  It  does  not  follow,  however,  that  the 
foetus  is  affected,  as  Serres  has  collected  22  cases  in  which  women, 
suffering  from  smallpox,  gave  birth  to  children  who  had  not  con- 
tracted the  disease.  It  has  been  supposed  that,  in  such  cases,  the 
child  is  protected  from  smallpox,  though  it  has  shown  no  symptom 
of  having  had  the  disease,  Tarnier,  however,  cites  two  instances  in 
which  such  children  had  smallpox  two  years  after  birth.  Madge 
and  Simpson  record  cases  in  which  vaccination  performed  on  the 
mother  during  pregnancy  protected  the  foetus,  on  whom  all  subse- 
quent attempts  at  vaccination  failed.  There  is  evidence  also  to 
prove  that  the  disease  may  be  transmitted  to  the  foetus  through  a 
mother,  who  is  herself  unsusceptible  of  contagion;  the  child  having 
been  covered  with  smallpox  eruption,  the  mother  being  quite  free 
from  it.  It  is  probable,  that  the  same  facts  which  have  been  ob- 
served with  regard  to  smallpox,  hold  true  with  reference  to  other 
zymotic  diseases,  such  as  scai-let  fever  and  measles,  although  there  is 
not  sufficient  evidence  to  justify  a  positive  assertion  to  that  effect. 

Measles  and  Scarlet  Fever. — Amongst  other  maternal  diseases,  mala- 
rious and  lead  poisoning  are  known  to  affect  the  foetus  in  utero.  Dr. 
Stokes  relates  cases  in  which  the  mother  suffered  from  tertian  ague, 
the  child  having  also  attacks,  as  evidenced  by  its  convulsive  move- 
ments, appreciable  by  the  mother,  which  took  place  at  the  regular 
intervals,  but  at  a  different  time  from  the  mother's  paroxysms.  In 
other  cases  the  febrile  paroxysm  comes  on  at  the  same  time  in  the 
foetus  as  in  the  mother;  and  the  fact  has  been  verified  by  the  observa- 
tion that  the  paroxysms  continued  to  recur  simultaneously  after 
delivery.  The  foetus  has  also  been  born  with  distinct  malarious 
enlargement  of  the  spleen.  From  the  frequency  with  which  largely 
hypertrophied  spleens  are  seen  in  mere  infants  in  malarious  districts, 
I  imagine  that  the  intra-uterine  disease  must  be  common.  I  have 
frequently  observed  this  fact  in  India,  although,  of  course,  without 
any  possibility  of  ascertaining  if  the  mothers  had  suffered  from  inter- 
mittent fever  during  pregnancy.  Lead-poisoning  is  also  known  to 
have  a  most  prejudicial  effect  on  the  foetus,  and  frequently  to  lead  to 
abortion.  M.  Paul  has  collected  81  cases, ^  in  which  it  caused  the 
death  of  the  foetus,  in  some  not  until  after  birth;  and  occasionally  it 
seems  to  have  affected  the  foetus  even  when  the  mother  escaped. 

Syphilis. — Of  all  blood  dyscrasise  transmitted  to  the  foetus,  the 
most  important  is  syphilis.  Its  influence  in  producing  repeated 
abortion  has  been  elsewhere  described.  It  may  unquestionably  be 
transmitted  to  the  foetus  without  producing  abortion,  and  at  term 
the  mother  may  be  either  delivered  of  a  living  child,  bearing  evi- 

1  Arch.  Gen.  de  Med.,  1860. 


PATHOLOGY    OF    THE    DECIDUA    AND    OVUM.  231 

dent  traces  of  the  disease;  of  a  dead  child  similarly  affected;  or  of 
an  apparently  healthy  child  in  whom  the  disease  develops  itself 
after  a  lapse  of  a  month  or  two.  These  varying  effects  probably  de- 
pend on  the  intensity  of  the  poison,  and  the  longer  the  time  that  has 
elapsed  since  the  origin  of  the  disease  in  the  infected  parents,  the 
better  will  be  the  chance  for  the  child.  The  disease  is,  no  doubt, 
generally  transmitted  through  the  mother,  and  if  she  be  aftected  at 
the  time  of  conception,  the  infection  of  the  foetus  seems  certain.  If, 
however,  she  contracts  the  disease  at  an  advanced  period  of  preg- 
nancy the  child  may  entirely  escape.  Ricord  even  believes  that 
syphilis,  contracted  after  the  sixth  month  of  pregnancy,  never  affects 
the  child.  The  father  alone  may  transmit  the  disease  to  the  ovum ; 
and  Hutchinson  has  recorded  cases  to  show  that  the  mother  may 
become  secondarily  affected  through  the  diseased  foetus.  The  evi- 
dences of  syphilitic  taint  in  a  living  or  dead  child  are  sufficiently 
characteristic.  The  child  is  generally  puny  and  ill-developed.  An 
eruption  of  pemphigus  is  common,  either  fully  developed  bullae,  or 
their  early  stage,  when  they  form  circular  copper-colored  patches. 
This  eruption  is  always  most  marked  on  the  hands  and  feet,  and  a 
child  born  with  such  an  eruption  may  be  certainly  considered  syphi- 
litic. On  post-mortem  examination  the  most  usual  signs  are  small 
patches  of  suppuration  in  the  thymus,  similar  localized  suppurations 
in  the  tissues  of  the  lungs,  indurated  yellowish  patches  in  the  liver, 
and  peritonitis,  the  importance  of  which  in  causing  the  death  of 
syphilitic  children  has  been  specially  dwelt  on  by  Simpson.^ 

Inflammatory  Diseases. — The  most  important  of  the  inflammatory 
diseases  affecting  the  foetus  is  peritonitis.  Simpson  has  shown  that 
traces  of  it  are  very  frequently  met  with,  and  that  it  is  not  always 
syphilitic.  Sometimes  it  has  been  observed  when  the  mother  has 
been  in  bad  health  during  pregnancy,  and  at  others  it  seems  to  have 
resulted  from  some  morbid  condition  of  the  foetal  viscera.  Pleurisv 
with  effusion,  is  another  inflammatory  affection  which  has  been 
noticed. 

Droi^sies. — The  dropsical  affections  most  generally  met  with  are 
ascites  and  hydrocephalus,  which  may  both  have  the  effect  of  im- 
peding delivery.  Of  these  hydrocephalus  is  the  more  common,  and 
may  give  rise  to  much  difficulty  in  labor.  Its  causes  are  uncertain 
but  it  probably  depends  on  some  altered  state  of  the  mother's  health, 
as  it  is  apt  to  recur  in  several  successive  pregnancies,  and  is  not  in- 
frequently associated  with  an  imperfectly  developed  vertebral  column 
and  spina  bifida.  The  fluid  collects  in  the  ventricles,  which  it 
greatly  distends,  and  these  then  produce  expansion  and  thinning  of 
the  cranium,  the  bones  of  which  are  widely  separated  from  each 
other  at  the  sutures,  which  are  prominent  and  fluctuating.  In  a 
few  cases  internal  hydrocephalus  may  be  complicated,  and  the  diag- 
nosis in  labor  consequently  obscured,  by  the  coexistence  of  what 
has  been  called  "  external  hydrocephalus."  This  consists  of  a  collec- 
iion  of  fluid  between  the  skull  and  the  scalp,  which  may  be  either 

>  Obst.  Works,  vol.  i.  p.  117. 


232 


PREGNANCY. 


Fig.  89. 


formed  there  originally,  or  may  collect  from  a  rupture  of  one  of  the 
sutures  or  fontauelles  during  labor,  through  which  the  intra- cranial 
fluid  escapes. 

Ascites  is  generally  associated  with  hydramnios,  and  sometimes 
with  hydro- thorax,  or  other  dropsical  effusions.  It  is  a  rare  affec- 
tion, and  according  to  DepauP  extreme  distension  of  the  bladder  is 
not  infrequently  mistaken  for  it. 

Tumors  of  different  kinds  may  be  met  with  in  various  parts  of  the 
child's  body,  which  sometimes  grow  to  a  great  size  and  impede  de- 
livery. Tarnier  records  cases  of  meningocele  larger  than  a  child's 
head,  and  large  cystic  growths  have  been  observed  attached  to  the 
nates,  pectoral  region,  or  other  parts  of  the  body.  Cancerous  tumors 
of  considerable  size,  either  external,  or  of  the  viscera,  have  also  been 
met  with.  Other  foetal  tumors  may  be  produced  by  congenital  de- 
formities, such  as  projection  of  the  liver  or  other  abdominal  viscera 
through  a  deficiency  of  the  abdominal  wall ;  or  spina  bifida,  from 
imperfectly  developed  vertebras.  The  amount  of  dystocia  produced 
by  such  causes  will,  of  course,  vary  much  in  proportion  to  the  size, 
consistency,  and  accessibility  of  the  tumor. 

Wounds  and  Injuries  of  the  Foetus. — Accidents  of  serious  gravity 
to  the  foetus  may  happen  from  violence,  to  which  the  mother  has 

been  subjected,  such  as  falls  or  blows,  with- 
out necessarily  interfering  with  gestation. 
Many  curious  examples  of  this  kind  are  on 
record.  Thus  a  child  has  been  born  pre- 
senting a  severe  lacerated  wound  extending 
the  whole  length  of  the  spine,  where  both 
the  skin  and  the  muscles  had  been  torn,  and 
which  seems  to  have  resulted  from  the  mother 
having  fallen  in  the  last  month  of  preg- 
nancy. Similar  lacerations  and  contusions 
have  been  observed  in  other  parts  of  the 
body,  the  wounds  being  in  various  stages 
of  cicatrization,  corresponding  to  the  lapse 
of  time  since  the  accident  had  occurred. 
Intra-uterine  fractures  are  not  rare,  appa- 
rently arising  from  similar  causes.  In  some 
of  these  cases  the  broken  ends  of  the  bones 
had  united,  but,  from  want  of  accurate  ap- 
position, at  an  acute  angle,  so  as  to  give 
rise  to  much  subsequent  deformity.  Chaus- 
sier  records  two  cases  in  which  there  were  many  fractures  in  the  same 
child,  in  one  113,  and  in  another  42,  which  were  in  different  stages 
of  repair.  He  attributes  this  curious  occurrence  to  some  congenital 
defect  in  the  nutrition  of  the  bones,  ])ossibly  allied  to  mollifies  ossium." 
Intra-uterine  amputations  of  foetal  lirnhs  have  not  infrequently  been 
observed.     Children  are  occasionally  born  with  one  extremity  more 


Intia-uteriue  Amputation  of  both. 
Arms  and  Legs. 


'  Tarnier's  Cazeaux,  p.  855. 


2  Gazette  Hebdom.,  ISoO. 


TATIIOLOGY    OP    THE    DECIDUA    AND    OVUM.  233 

or  less  completely  absent,  and  cases  are  known  in  which  the  whole 
four  extremities  were  wanting  (Fig.  89).  The  mode  in  which  these 
malformations  are  produced  has  given  rise  to  much  discussion.  At 
one  time  it  was  supposed  that  the  deficiency  of  the  limb  was  due  to 
gangrene  of  the  extremity,  and  subsequent  separation  of  the  spha- 
celated parts.  Keuss,  who  has  studied  the  whole  subject  very 
minutely,^  considers  gangrene  in  the  unruptured  ovum  to  be  an  im- 
possibility, for  that  change  cannot  occur  unless  there  is  access  of 
oxygen,  and  when  portions  of  the  separated  extremity  are  found  in 
utero,  as  is  often  the  case,  they  show  evidences  of  maceration,  but 
not  of  decomposition.  The  general  belief  is  that  these  intra-uterine 
amputations  depend  on  constriction  of  the  limb  by  folds  or  bands  of 
the  amnion — most  often  met  with  when  the  liquor  amnii  is  deficient 
in  quantity — ^wliich  obstruct  the  circulation,  and  thus  give  rise  to 
atrophy  of  the  part  below  the  constriction.  It  has  been  supposed 
that  the  umbilical  cord  might,  by  encircling  the  limb,  produce  a  like 
result.  It  appears  doubtful,  however,  whether  this  cause  is  suflficient 
to  produce  complete  separation  of  the  limb,  as  any  great  amount  of 
constriction  would  interfere  with  the  circulation  through  the  cord. 
Sometimes,  when  intra-uterine  amputation  occurs,  the  separated 
portion  of  the  limb  is  found  lying  loose  in  the  amniotic  cavity,  and 
is  expelled  after  the  child.  Cases  of  this  kind  have  been  recorded 
by  Martin,  Ohaussier,  and  Watkinson.  More  o'ften  no  trace  of  the 
separated  extremity  can  be  found.  The  explanation  probably  de- 
pends upon  the  period  of  utero-gestation  at  which  amputation  took 
place.  If  it  occurred  at  a  very  early  period  of  pregnancy,  before  the 
third  month,  the  detached  portion  Avould  be  minute  and  soft,  and 
would  easily  disappear  by  solution.  If  at  a  later  period,  this  could 
hardly  happen,  and  the  detached  portion  would  remain  in  utero.  In 
cases  of  the  latter  kind  cicatrization  of  the  stump  has  often  been  ob- 
served to  be  incomplete.  Simpson  pointed  out  the  occasional  exist- 
ence of  rudimentary  fingers  or  toes  on  the  stump  of  an  amputated 
limb,  suc-h  as  are  seen  on  the  thighs  in  Fig.  89.  These  he  attributed 
to  an  abortive  reproduction  of  the  separated  extremity,  analogous  to 
what  is  observed  in  some  of  the  lower  animals.  This  explanation 
has  been  contested  with  much  show  of  reason.  Martin  believes  that 
the  reproduction  is  only  apparent,  and  that  the  rudimentary  ex- 
tremities are,  in  reality,  instances  of  arrested  development. "  The 
constricting  agents  interfered  with  the  circulation  sufficiently  to 
arrest  the  growth  of  the  limb  below  the  site  of  constriction,  but  not 
sufficiently  to  effect  complete  separation.  If  constriction  occurred 
at  a  very  early  stage  of  development  an  appearance  similar  to  that 
observed  by  Simpson  would  be  produced.  It  does  not  follow,  how- 
ever, that  all  cases  of  absence  of  limbs  depend  on  intra-uterine  ampu- 
tations. In  some  cases  they  would  appear  to  be  the  result  of  a  sponta- 
neous arrest  of  development,  or  of  congenital  monstrosity.  Mr.  Scott^ 
relates  a  case  in  which  a  distinct  hereditary  tendency  was  evident, 

>  Scanzoni's  Beitrage,  1869.  2  Obstet.  Trans.,  vol.  xiii.  p.  94. 

16 


231  PREGNANCY. 

and  here  the  deformity  certainly  could  not  have  resulted  from  the 
constriction  of  amniotic  bands.  In  this  family  the  grandfather  had 
both  forearms  wanting,  with  rudimentary  fingers  attached ;  the  next 
generation  escaped ;  but  the  grandchild  had  a  deformity  precisely 
similar  to  the  grandfather. 

Death  of  FcEtus. — When  from  any  cause,  the  foetus  has  died  during 
pregnancy,  it  may  either  be  soon  expelled,  or  it  may  be  retained  in 
utero  for  a  longer  or  shorter  time,  or  even  to  the  full  period.  The 
changes  observed  in  such  foetuses  vary  considerably  according  to  the 
age  of  the  foetus  at  the  time  of  death,  or  the  time  that  it  has  been 
retained  in  utero.  If  it  die  at  an  early  period,  when  the  tissues  are 
very  soft,  it  may  entirely  dissolve  in  the  liquor  amnii,  and  no  trace 
of  it  may  be  found  when  the  membranes  are  expelled.  Or  it  may 
shrivel  or  mummify  ;  and  if  this  happen  in  a  twin  pregnancy,  as 
sometimes  occurs,  the  growing  foetus  may  compress  and  flatten  the 
dead  one  against  the  uterine  wall. 

Appearance. — At  a  later  period  of  pregnancy  a  dead  foetus  under- 
goes changes  ascribed  to  putrefaction,  but  which  produce  appearances 
different  from  those  of  decomposition  in  animal  textures  exposed  to 
the  atmosphere.  There  is  no  offensive  smell,  as  in  ordinary  decay. 
The  tissues  are  all  softened  and  flaccid.  The  moi"e  manifest  changes 
are  in  the  skin,  the  epidermis  of  which  is  separated  from  the  cutis 
vera,  which  has  a  deep  reddish  color.  This  is  especially  apparent  on 
the  abdomen,  which  is  flaccid,  and  hollow  in  the  centre.  The  inter- 
nal organs  are  much  altered.  The  brain  is  diffluent  and  pulpy,  and 
the  cranial  bones  loose  within  the  scalp.  The  structures  of  the  mus- 
cles and  viscera  are  in  various  stages  of  transformation,  many  having 
undergone  fatty  changes,  and  containing  crystals  of  margarin  and 
cholesterin.  The  extent  to  which  these  changes  occur  depends,  to  a 
great  extent,  on  the  length  of  time  the  foetus  has  been  dead,  but  they 
do  not  admit  of  our  estimating  with  any  degree  of  accuracy  what 
that  time  has  been. 

The  symptoms  and  diagnosis  of  the  death  of  the  foetus  may  here  be 
considered.  They  are,  unfortunately,  not  very  reliable.  The  cessa- 
tion of  the  foetal  movements  cannot  be  depended  on,  as  they  are 
frequently  unfelt  for  days  or  weeks,  when  the  child  is  alive  and  well. 
Sometimes  the  death  of  the  foetus  is  preceded  by  its  irregular  and 
tumultuous  movements,  and,  in  women  who  have  been  delivered  of 
several  dead  children  in  succession,  this  sensation  may  guide  us  in 
our  diagnosis.  This  suspicion  may  be  confirmed  bj^  auscultation. 
The  mere  fact  that  we  are  unable,  at  any  given  time,  to  hear  the 
foetal  heart  will  not  justify  an  opinion  that  the  foetus  is  dead.  If, 
however,  the  foetal  heart  has  been  distinctly  heard,  and  after  one  or 
two  careful  examinations,  repeated  at  separate  times,  it  cannot  again 
be  made  out,  the  probability  of  the  child  being  dead  may  be  assumed. 
Certain  changes  in  the  mother's  health  have  been  noted  in  connec- 
tion with  the  death  of  the  foetus,  such  as  depression  and  lowness  of 
spirits,  a  feeling  of  coldness  and  weight  about  the  lower  parts  of  the 
abdomen,  paleness  of  the  face,  a  livid  circle  round  the  eyes,  irregular 
shiverings  and  feverishness,  shrinking  of  the  breasts,  and  diminution 


ABORTION    AND    PREMATURE    LABOR.  285 

in  the  size  of  the  abdominal  tumor.  All  these,  however,  are  too  in- 
definite to  justify  a  positive  diagnosis,  and  they  are  not  infrequently 
altogether  absent.  At  most  they  can  do  no  more  than  cau.so  a  sus- 
picion as  to  what  has  happened. 


CHAPTEK    X. 

ABORTION   AND   PREMATURE    LABOR. 

Importance  and  Frequency  of  Ahortion. — The  premature  expulsion 
of  the  fcetus  is  an  event  of  great  frequency.  The  number  of  foetal 
lives  thus  lost  is  enormous.  There  are  few  multiparte  who  have  not 
aborted  at  one  time  or  other  of  their  lives.  Hegar  estimates  that 
about  one  abortion  occurs  to  every  8  or  10  deliveries  at  term.  White- 
head has  calculated  that  at  least  90  per  cent,  of  married  woman,  who 
lived  to  the  change  of  life,  had  aborted.  The  influence  of  this  acci- 
dent on  the  future  health  of  the  mother  is  also  of  great  importance. 
It  rarely,  indeed,  proves  directly  fatal,  but  it  often  produces  great 
debility  from  the  profuse  loss  of  blood  accompanying  it ;  and  it  is 
one  of  the  most  prolific  causes  of  uterine  disease  in  after  life,  possibly 
because  women  are  apt  to  be  more  careless  during  convalescence  than 
after  delivery,  and  the  proper  involution  of  the  uterus  is  thus  more 
frequently  interfered  with. 

Definition. — 'A  not  uncommon  division  of  the  subject  is  into  ahor- 
tion^ miscarriage,  and  premature  labor^  the  first  name  being  applied 
to  expulsion  of  the  ovum  before  the  end  of  the  fourth  month  of  utero- 
gestation  ;  miscarriage  to  expulsion  from  the  end  of  the  fourth  to  the 
end  of  the  sixth  month  ;  and  premature  labor  to  expulsion  from  the 
end  of  the  sixth  month  to  the  term  of  pregnancy.  This  is,  however, 
a  needless  and  confusing  subdivision,  which  leads  to  no  practical 
result.  It  suffices  to  apply  the  term  abortion  or  miscarriage  indis- 
crimately  to  all  cases  in  which  pregnancy  is  terminated  before  the 
foetus  has  arrived  at  a  viable  age,  and  premature  labor  to  those  in 
which  there  is  a  possibility  of  its  survival.  There  is  little  or  no 
hope  of  a  foetus  living  before  the  2(Sth  week  or  seventh  lunar  month, 
and  this  period  is  therefore  generally  fixed  on  as  the  limit  between 
premature  labor  and  abortion.  The  rule,  is  however,  not  without 
an  occasional,  although  very  rare,  exception.  Dr.  Keiller,  of  Edin- 
burgh, has  recorded  an  instance  in  which  a  foetus  was  born  alive  at 
the  fourth  month,  nine  days  after  the  mother  had  experienced  the 
sensation  of  quickening.  I  myself  recently  attended  a  lady  who  mis- 
carried in  the  fifth  month  of  pregnancy,  the  child  being  born  alive, 
and  living  for  three  hours.  Several  cases  are  on  record  in  which 
after  delivery  at  the  sixth  month  the  child  survived  and  was  reared. 


236  PREGNANCY. 

The  possibility  of  the  birth  of  a  living  child  under  such  circum- 
stances should  be  recognized,  at  it  may  give  rise  to  legal  questions 
of  importance ;  but  the  exceptions  to  the  ordinary  rule  are  so  rare, 
that  they  need  not  interfere  with  the  division  of  the  subject  usually 
made. 

Abortion  is  most  Coramon  in  MuUiparw. — Multiparge  abort  far  more 
frequently  than  primiparse.  This  is  contrary  to  the  statement  in  many 
obstetrical  works.  Thus,  Tyler  Smith  says  "  there  seems  to  be  a 
greater  danger  of  this  accident  in  the  first  pregnancy."  Schroeder,^ 
however,  states  that  23  multiparse  abort  to  3  primiparse ;  and  Dr. 
Whitehead,  of  Manchester,  who  has  particularly  studied  the  subject, 
believes  that  abortion  is  more  apt  to  occur  after  the  third  and  fourth 
pregnancies,  especially  when  these  take  place  towards  the  time  for 
the  cessation  of  menstruation. 

Liability  to  a  recurrence  of  Abortion. — There  can  be  no  doubt  that 
women  who  have  aborted  more  than  once  are  peculiarly  liable  to  a 
recurrence  of  the  accident.  This  can  generally  be  traced  to  the  exist- 
ence of  some  predisposing  cause  which  persists  through  several  preg- 
nancies, as,  for  example,  a  syphilitic  taint,  a  uterine  flexion,  or  a 
morbid  state  of  the  lining  membrane  of  the  uterus.  It  is  probable 
that  in  many  women  a  recurrence  of  the  accident  induces  a  habit 
of  abortion,  or,  perhaps  it  might  be  more  accurate  to  say,  a  peculiar 
irritable  condition  of  the  uterus,  which  renders  the  continuance  of 
pregnancy  a  matter  of  difficulty,  independently  of  any  recognizable 
organic  cause. 

Very  early  Abortions  are  often  Unrecognized. — The  frequency  of 
abortion  varies  much  at  different  periods  of  pregnancy  ;  and  it  occurs 
much  more  often  in  the  early  months,  because  of  the  comparatively 
slight  connection  then  existing  between  the  chorion  and  the  decidua. 
At  a  very  early  period  of  pregnancy  the  ovum  is  cast  off  with  such 
facility,  and  is  of  such  minute  size,  that  the  fact  of  abortion  having 
occurred  passes  unrecognized.  Very  many  cases,  in  which  the  patient 
goes  one  or  two  weeks  over  her  time,  and  then  has  what  is  supposed 
to  be  merely  a  more  than  usually  profuse  period,  are  probably  in- 
stances of  such  eai^ly  miscarriages.  Velpeau  detected  an  ovum,  of 
about  fourteen  days,  which  was  not  larger  than  an  ordinary  pea,  and 
it  is  easy  to  understand  how  so  small  a  body  should  pass  unnoticed 
in  the  blood  which  escapes  along  with  it. 

Abortions  before  the  Third  Month  and  between  the  Third  and  Sixth. 
— Up  to  the  end  of  the  third  month,  when  miscarriage  occurs,  the 
ovum  is  generally  cast  off"  en  masse,  the  decidua  subsequently  coming 
away  in  shreds,  or  as  an  entire  membrane.  The  abortion  is  then 
comparatively  easy.  From  the  third  to  the  sixth  month,  after  the 
placenta  is  formed,  the  amnion  is,  as  a  rule,  first  ruptured  by  the 
uterine  contractions,  and  the  foetus  is  expelled  by  itself.  The  pla- 
centa and  membranes  may  then  be  shed  as  in  ordinary  labor.  It 
often  happens,  however,  that  on  account  of  the  firmness  of  the  pla- 
cental adhesion  at  this  period,  the  secundines  are   retained   for  a 

'  Schroeder,  Manual  of  Midwifery,  p.  14y. 


ABORTION     AND    PREMATURE    LAUOR.  237 

greater  or  less  length  of  time.  This  subjects  tlic  patient  to  many 
risks,  especially  to  those  of  profuse  heniori'liage,  and  of  septicajuiia. 
For  this  reason,  premature  termination  of  the  pregnancy  is  attended 
by  much  greater  danger  to  the  mother  between  the  third  and  sixth 
months,  than  at  an  earlier  or  later  date.  After  the  sixtli  month  the 
course  of  events  is  not  dift'erent  from  that  attending  ordinary  labor. 
The  prognosis  to  the  child  is  more  unfavorable  in  proportion  to  the 
distance  from  the  full  period  of  gestation  at  which  premature  labor 
takes  place. 

Causes. — The  causes  of  abortion  may  conveniently  be  subdivided 
into  the  predispusing  and  exciiinrj^  the  latter  being  often  slight,  and 
such  as  would  have  no  effect  in  inducing  uterine  contractions  in 
women  unless  associated  with  one  or  more  of  the  former  class  of 
causes.  The  predisposition  to  abortion  may  depend  on  some  condi- 
tion interfering  with  the  vitality  of  the  ovum,  or  its  relation  to  the 
maternal  structures,  or  on  certain  conditions  directly  affecting  the 
mother's  health. 

Causes  referable  to  the  Foetus. — One  of  the  most  common  antece- 
dents of  abortion  is  the  death  of  the  foetus,  which  leads  to  secondary 
changes,  and  ultimately  produces  the  uterine  contractions  which  end 
in  its  expulsion.  The  precise  causes  of  death  in  any  given  case  can 
not  always  be  accurately  ascertained,  as  they  sometimes  depend  on 
conditions  which  are  traceable  to  the  maternal  structures,  at  others 
to  the  ovular,  or,  it  may  be,  to  a  combination  of  the  two.  Nor  does 
it  by  any  means  follow  that  the  death  of  the  ovum  immediately 
results  in  its  expulsion.  The  mode  in  which  death  of  the  ovum  pro- 
duces abortion  is  not  difficult  to  understand,  for  it  necessarily  leads  to 
changes  in  the  relations  between  the  ovular  and  maternal  structures; 
these  changes  cause  hemorrhages — partly  external,  and  partly  into 
the  membranes — which,  in  their  turn,  excite  uterine  contraction. 
Extravasations  of  blood  may  take  place  in  various  positions.  One 
of  the  most  common  is  into  the  decidual  cavity,  between  the  decidua 
vera  and  the  decidua  reflexa — or  between  the  decidua  vera  and  the 
uterine  walls.  If  the  hemorrhage  is  only  slight,  and  especially  if  it 
comes  from  that  portion  of  the  decidua  near  the  internal  os.  and  at 
a  distance  from  the  ovum,  there  need  be  no  material  separation,  and 
pregnancy  may  continue.  This  explains  the  cases  occasionally  met 
with,  in  which  there  is  more  or  less  hemorrhage,  without  subsequent 
abortion.  When  the  amount  of  extravasated  blood  is  at  all  great, 
separation  and  abortion  necessarily  result,  and  the  decidua  will  be 
found  on  expulsion  to  have  coagula  on  its  surface,  and  between  its 
various  layers  which  are  found  to  project  into  the  cavity  of  the 
amnion  (Fig.  90).  In  other  cases  hemorrhage  is  still  more  extensive, 
and,  after  breaking  through  the  decidua  reflexa,  it  forms  clots  between 
it  and  the  chorion,  and  even  in  the  cavity  of  the  amnion.  Supposing 
expulsion  to  take  place  shortly  after  coagula  are  deposited  among  the 
membranes,  the  blood  is  little  altered,  and  we  have  an  ordinary 
abortion.  If,  however,  the  ovum  is  retained,  the  coagulated  fibrine, 
and  the  placenta  or  membranes,  undergo  secondary  changes,  which 
lead  to  the  formation  of  moles.     The  so-called  fleshy  mole  (Fig.  91) 


238 


PREGNANCY, 


is  often  retained  for  many  weeks  or  months  after  the  death  of  the 
foetus,  and  during  this  time  there  may  be  but  little  modification  of 


Fm.  90. 


Aa  Apoplectic  Ovum,  ■with  Blood  effused  ia  Masses  under  the  Toetal  Surface  of  the  Membrane. 

the  usual  symp-toms  of  pregnancy ;  or,  as  is  frequently  the  case,  it 
gives  rise  to  occasional  hemorrhage,  until  at  last  uterine  contractions 


Blighted  Ovum,  with  Fleshy  Degeneration  of  the  Membrane. 

come  on,  and  it  is  cast  off  in  the  form  of  a  thick  fleshy  mass,  having 
but  little  resemblance  to  the  ordinary  products  of  conception.     The 


ABORTION    AND    PREMATURE    LABOR.  239 

most  probable  explanation  of  its  formation  is,  that  when  hemorrhage 
originally  took  place,  the  effusion  of  blood  was  not  sufficient  to  effect 
the  entire  separation  and  expulsion  of  the  ovum.  Part  of  the  mem- 
branes, or  of  the  placenta — if  that  organ  had  commenced  to  form — 
retained  its  organic  connection  with  the  uterus,  while  the  foetus 
perished.  The  attached  portion  of  the  placenta  or  membranes  con- 
tinues to  be  nourished,  although  abnormally.  The  foetus  generally 
entirely  disappears,  especially  if  it  has  perished  at  an  early  ]»eriod  of 
utero-gestation,  when  it  becomes  dissolved  in  the  liquor  amnii.  Or 
it  may  become  macerated,  shrivelled,  and  greatly  altered  in  appear- 
ance. The  effused  blood  becomes  decolorized  from  the  absorption 
of  the  corpuscles ;  and,  according  to  Scanzoni,  fresh  vessels  are 
developed  in  the  fibrine,  which  increase  the  vascular  attachment  of 
the  mole  to  the  uterine  walls.  The  placenta  and  membranes  may 
go  on  increasing  in  thickness,  until  they  form  a  mass  of  considerable 
size.  Careful  microscopic  examination  will  almost  always  enable  us 
to  discover  the  villi  of  the  chorion,  altered  in  appearance,  often  loaded 
with  granular  fatty  molecules,  but  sufficiently  distinct  to  be  readily 
recognizable. 

Causes  depending  on  the  Maternal  State. — Important  as  are  the 
causes  of  abortion  arising  from  some  morbid  condition  of  the  ovum, 
they  are  not  more  so  than  those  which  depend  on  the  maternal  state, 
and  it  is  to  be  observed  that  the  former  are  often  indirect  canses, 
produced  by  primary  maternal  changes.  Many  of  these  maternal 
causes  act  by  causing  hypera3mia  of  the  uterus,  which  leads  to  ex- 
travasation of  blood.  Thus  abortion  is  apt  to  occur  in  women  who 
lead  unhealthy  lives,  such  as  those  who  occupy  over-heated  and  ill- 
ventilated  rooms,  or  indulge  to  excess  in  the  fatigues  and  pleasures 
of  society,  in  the  use  of  alcoholic  drinks,  and  the  like.  Over-frequent 
coitus  has  been,  for  the  same  reason,  observed  to  produce  a  remark- 
able tendency  to  abortion,  and  Parent-Duchatelet  has  noted  that  it 
is  of  very  frequent  occurrence  amongst  women  of  loose  life.  Many 
diseases  strongly  predispose  to  it,  such  as  fevers,  zymotic  diseases 
of  all  kinds,  measles,  scarlet  fever,  smallpox ;  and  diseases  of  the 
respiratory  organs,  such  as  bronchitis  and  pneumonia.  Syphilis  is 
well  known  to  be  one  of  the  most  frequent  causes,  and  one  that  is 
likely  to  act  in  successive  pregnancies.  It  may  act  so  that  the  preg- 
nancy is  brought  to  a  premature  termination,  time  after  time,  until 
the  constitutional  disease  is  eradicated  by  appropriate  treatment.  It 
acts  in  some  cases  through  the  influence  of  the  father  in  producing  a 
diseased  ovum ;  and  it  is  the  only  cause  which  can  with  certainty  be 
traced  to  the  state  of  the  father's  health.  Many  other  morbid  condi- 
tions of  the  blood  also  dispose  to  abortion.  It  has  been  observed  to 
be  a  frequent  result  of  lead-poisoning  ;  also  of  the  presence  of  noxious 
gases  in  the  atmosphere,  such  as  an  excess  of  carbonic  acid. 

Causes  acting  through  the  Nervous  Systern. — Many  causes  act  througli 
the  nervous  system,  such  as  fright,  anxiety,  sudden  shock,  and  the 
like.  Thus  there  are  numerous  instances  on  record  in  which  women 
aborted  suddenly  after  the  receipt  of  some  bad  news,  and  it  is  said  to 
have  been  of  frequent  occurrence  in  women  immediately  before  exe- 


240  PKEGNANCY. 

cution.  The  influence  of  irritation  propagated  through  the  nervous 
system  from  a  distance,  tending  to  produce  uterine  contraction  and 
abortion  through,  the  agency  of  reflex  action,  has  been  specially 
dwelt  upon  by  Tyler  Smith.  Tlius  he  points  out  that  abortion  not 
unfrequently  occurs  from  the  irritation  of  constant  suckling  in  women 
who  become  pregnant  during  lactation.  The  efi'ect  of  suckling 
in  producing  uterine  contraction  is,  indeed,  well  known,  and  the  ap- 
plication of  the  child  to  the  breast,  for  this  purpose,  has  long  been 
recognized  as  a  method  of  treatment  in  post-partum  hemorrhage. 
The  irritation  of  the  trifacial  in  severe  toothache  ;  of  the  renal  nerves 
in  cases  of  gravel,  in  albuminuria,  etc,  ;  of  the  intestinal  nerves  in 
excessive  vomiting,  in  diarrhoea,  obstinate  constipation,  ascarides, 
etc.,  all  act  in  the  same  way.  We  may,  perhaps,  also  explain,  by 
this  hypothesis,  the  fact,  that  women  are  more  apt  to  abort  at  what 
would  have  been  the  menstrual  epoch,  than  at  other  times,  as  the 
ovarian  nerves  may  then  be  subject  to  undue  excitement.  It  is  prob- 
able, however,  that  there  may  be  also  at  these  times  more  or  less 
active  congestion  of  the  decidua,  which  may  predispose  to  laceration 
of  its  capillaries  and  blood  extravasation.  Such  congestion  exists  in 
those  exceptional  cases  in  which  menstruation  continues  for  one  or 
more  periods  after  conception,  the  blood  probably  escaping  from  the 
space  between  the  decidua  vera  and  reflexa ;  and,  therefore,  there  is 
no  reason  to  question  its  also  happening  even  when  such  abnormal 
menstruation  is  not  present. 

Physical  Causes. — Certain  physical  causes  may  produce  abortion 
by  separating  the  ovum.  Thus  it  may  follow  a  fall,  a  blow,  or  other 
accidents  of  a  trivial  character.  On  the  other  hand,  women  may  be 
subjected  to  injuries  of  the  severest  kind  without  aborting.  The 
prol3abilitv,  therefore,  is  that  these  apparently  trivial  causes  only 
operate  in  women  who,  for  some  other  reason,  are  predisposed  to  the 
accident.  This  is  borne  out  by  the  fact — which  is  well  known  in 
these  days,  when  the  artificial  production  of  abortion  is,  unhappily, 
far  from  a  very  rare  event — that  it  is  by  no  means  easy  to  destroy 
the  vitality  of  the  foetus,  I  myself  know  of  a  case,  in  which  the 
uterine  sound  was  passed  several  times  into  a  pregnant  uterus  with- 
out producing  abortion,  the  pregnancy  proceeding  to  term.  Oldham 
has  related  a  similar  case  in  which  he  in  vain  attempted  to  induce 
abortion  by  the  sound  in  a  case  of  contracted  pelvis ;  and  Duncan 
has  mentioned  an  instance  in  which  an  intra-uterine  stem  pessary 
was  unwittingly  introduced,  and  worn  for  some  time  by  a  pregnant 
woman,  without  any  bad  effect.  The  fact  that  pregnancy  is  with 
dilficulty  interfered  with  when  there  is  a  healthy  relation  between 
the  ovum  and  the  uterus,  no  doubt,  explains  the  disastrous  efi^'ects  of 
criminal  abortion,  which  have  been  es23ecially  insisted  on  by  many 
of  our  American  brethren. 

Causes  dependinr/  on  Morbid  States  of  the  Uterus. — Morbid  states  of 
the  uterus  have  an  important  influence  in  the  production  of  abortion. 
Any  condition  which  mechanically  interferes  with  the  proper  develop- 
ment of  the  uterus  is  apt  to  operate  in  this  way.  Amongst  these 
may  be  mentioned  libroid  tumors  ;  the  presence  of  old  peritoneal 


ABORTION    AND    PREMATURE    LABOR.  241 

adhesions,  rendering  the  womb  a  more  or  less  fixed  organ  ;  but, 
above  all,  flexion  and  displacement  of  the  uterus.  Ketrotlexion  of 
the  uterus  is,  unquestionably,  one  of  the  most  frequent  factors  in  its 
production,  not  only  on  account  of  the  irritation  which  the  abnormal 
position  sets  up,  but  from  interference  with  the  uterine  circulation, 
which  leads  to  the  effusion  of  blood,  and  the  death  of  the  ovum. 
An  inflamed  condition  of  the  cervical  and  uterine  mucous  mem- 
branes will  act  in  the  same  way,  should  pregnancy  have  occurred  ; 
although  such  a  condition  more  often  prevents  conception  taking 
place. 

Symptoms. — One  of  the  earliest  indications  of  impending  abortion 
is  more  or  less  hemorrhage.  This  may  at  first  be  slight,  and  may 
last  for  a  short  time  only,  recurring  after  an  interval  of  time;  or  it 
may  commence  with  a  sudden  and  profuse  discharge.  Occasionally 
it  is  very  abundant,  and  its  continuance  and  amount  form  one  of  the 
gravest  symptoms  of  the  accident.  After  the  loss  of  blood  has  con- 
tinued for  a  greater  or  less  length  of  time — it  may  be  even  for  some 
days — -uterine  contractions  come  on,  recurring  at  regular  intervals, 
and  eventually  lead  to  the  expulsion  of  the  ovum.  More  rarely  the 
impending  miscarriage  commences  with  pains,  which  lead  to  lacera- 
tion of  vessels  and  hemorrhage. 

When  Pain  and  Flemorrhaye  coexist. — As  long  as  one  or  other  of 
these  symptoms  exists  alone,  we  may  hope  to  avert  the  threatened 
miscarriage;  but  when  both  occur  together  there  is  little  or  no 
chance  of  its  being  arrested.  C^irtain  premonitory  symptoms  are  de- 
scribed by  authors  as  common  in  abortion,  such  as  feverishness, 
shivering,  a  sensation  of  coldness;  all  of  which  are  obscure  and  un- 
reliable, and  are  certainl^y  much  more  frequently  absent  than  present. 

If  the  pregnancy  be  early  it  is  probable  that  the  entire  ovum  will 
be  shed  with  little  trouble,  and  it  often  passes  unperceived  in  the 
clots  which  surround  it.  It  is,  therefore,  of  importance  that  all  the 
discharges  should  be  very  carefully  examined.  After  the  second 
month  the  rigid  and  undilated  cervix  presents  a  formidable  obstacle 
to  the  escape  of  the  ovum,  and  it  may  be  a  considerable  time  before 
there  is  sufficient  dilatation  to  admit  of"  its  passage.  This  is  gradually 
effected  by  the  continuance  of  pains,  but  not  without  a  severe  loss  of 
blood.  It  mav  be  that  the  amnion  is  ruptured,  and  the  foetus  ex- 
pelled first.  After  a  lapse  of  time  the  secundines  are  also  shed,  but 
there  may  be  a  considerable  delaj'-,  amounting  even  to  days,  before 
this  is  effected.  As  long  as  any  portions  of  the  membranes  are 
retained  in  uterb,  the  patient  is  necessarily  subjected  to  considerable 
risk,  not  only  from  the  continuance  of  hemorrhage,  but  also  from 
septicgemia.  Hence  it  may  be  laid  down  as  a  rule,  that  we  can  never 
consider  our  patient  out  of  danger  until  we  have  satisfied  ourselves 
that  the  whole  of  the  uterine  contents  have  been  expelled. 

Treatment. — Our  first  endeavor  in  2iX\j.  case  of  impending  miscar- 
riage will  be,  of  course,  to  avert  the  threatened  accident.  If  hemor- 
rhage has  not  been  excessive,  and  if,  on  vaginal  examination,  which 
should  always  be  practised,  we  find  no  dilatation  of  the  os,  we  may 
entertain  a  reasonable  hope  of  success.     If,  on  the  contrary,  we  find 


242  PREGNANCY. 

the  OS  beginning  to  open,  if  we  are  able  to  insert  the  linger  through 
it  so  as  to  touch  the  ovum,  especially  if  pains  also  exist,  we  are 
justified  in  considering  abortion  to  be  inevitable,  and  the  indication 
will  then  be  to  have  the  ovum  expelled,  and  the  case  terminated  as 
soon  as  possible.  In  the  former  case,  the  most  absolute  rest  is  the 
first  thing  to  insist  on.  The  patient  should  be  placed  in  bed,  not 
overburdened  with  clothes,  in  a  cool  temperature,  and  she  should 
have  a  light  and  easily  assimilated  diet.  All  movements,  even  rising 
out  of  bed  to  empty  the  bladder  or  bowels,  should  be  absolutely  pro- 
hibited. To  avert  ihe  tendency  to  the  commencement  of  uterine 
contraction  there  is  no  remedy  so  useful  as  opium,  which  must  be 
given  freely,  and  frequently  repeated.  It  may  be  administered  either 
in  the  form  of  laudanum,  or  of  Battley's  sedative  solution,  which  has 
the  advantage  of  producing  less  general  disturbance.  It  may  be 
advantageously  exhibited  in  doses  of  from  20  to  30  minims,  and  re- 
peated altei-  a  few  hours.  A  still  better  preparation  is  chlorodyne, 
which  I  have  found  of  extreme  value  in  arresting  impending  mis- 
carriage, in  doses  of  15  minims,  repeated  every  third  or  fourth  hour. 
Ifj  from  any  cause,  it  is  considered  unadvisable  to  give  the  sedative 
by  the  mouth,  it  may  be  administered  in  a  small  starch  enema  per 
rectum-.  In  all  cases  it  will  be  necessary  to  keep  the  patient  more  or 
less  under  the  influence  of  the  drug  for  several  days,  and  until  all 
symptoms  of  miscarriage  have  passed  away.  Care  should  be  taken 
that  the  bowels  do  not  become  locked  up  by  the  action  of  the  opiates 
— as  this  might  of  itself  be  a  cause  of  irritation — and  their  constipat- 
ing effects  ought  to  be  obviated  by  small  doses  of  castor  oil,  or  other 
gentle  aperient.  Various  subsidiary  methods  of  treatment  have  been 
recommended,  such  as  bleeding  from  the  arm,  or  the  local  applica- 
tion of  leeches  in  supposed  plethoric  states  of  the  system  ;  revulsives, 
such  as  dry  cupping  to  the  loins;  the  application  of  ice,  to  check 
hemorrhage;  astringents,  such  as  acetate  of  lead  or  gallic  acid,  for 
the  same  purpose.  Most  of  these,  if  not  hurtful,  will  be,  at  least, 
useless.  The  cases  in  which  venesection  would  be  beneficial  are  ex- 
tremely rare,  and  the  local  applications,  especially  cold,  are  much 
more  apt  to  favor,  than  to  prevent,  uterine  action. 

[  Value  of  Opium. — -As  an  instance  of  the  value  of  opium  in  arrest- 
ing abortion  under  unftivorable  circumstances,  I  refer  to  the  follow- 
ing case.  Mrs.  R.,  a  young  married  lady  in  affluent  circumstances,  the 
mother  of  two  children,  and  of  apparently  a  phthisical  tendency,  the 
disease  being  in  her  family,  was  taken  in  labor  at  4 J  months;  the 
intermittent  pains  being  very  decided,  and  the  loss  of  blood  con- 
siderable. Under  the  effects  of  morphia  given  at  intervals,  the  pains 
became  gradually  less  frequent  and  severe,  until  at  the  end  of  ten 
hours  they  ceased  entirely.  The  uterine  development  advanced 
without  any  more  interruption,  and  the  patient  gave  birth  to  a  living 
female  child  at  the  end  of  nine  months.  The  foetus  was  a  little  below 
the  average  in  weight,  but  lived. 

Viburnum.  Prunifolium,^  in  the  form  of  a  fluid  extract,  has  recently 
come^  into  notice  as  a  preventive  of  abortion,  especially  in  cases 


/ 


ALORTION  AND  PREMATURE  LABOR.  243 

where  there  appears  to  be  a  habit  to  abort  at  short  intervals.  Great 
claims  are  made  for  the  remed}'-,  which  is  under  trial  as  yet. — Ed.] 

Prophylactic  Treatment. — In  cases  of  repeated  miscarriage  in  suc- 
cessive pregnancies,  a  special  course  of  prophylactic  treatment  is 
indicated,  and  is  often  attended  with  much  success.  In  cases  of  this 
kind  the  first  indication,  and  one  which  ought  to  be  carefully  attended 
to,  is  to  seek  for  and,  if  possible,  to  remove  or  mitigate  the  cause 
which  has  given  rise  to  the  former  abortions.  Those  causes  which 
depend  on  constitutional  states  must  first  be  carefully  investigated, 
and  treated  according  to  the  indications  present.  These  may  be 
obscure  and  not  easily  discovered ;  but  it  is  certainly  unwise  to 
assume  too  readily  the  existence  of  what  has  been  called  "  a  habit  of 
abortion,"  which  further  inquiry  may  prove  to  be  only  an  indication 
of  constitutional  debility,  degeneracy  of  the  placental  structures,  or 
a  latent  and  unsuspected  syphilitic  taint.  If  constitutional  debility 
be  present  to  a  marked  extent,  a  generous  diet  and  a  restorative 
course  of  treatment  (preparations  of  iron,  quinine,  and  other  suitable 
tonics),  may  effect  the  desired  object. 

Treatment  in  cases  depending  on  Local  Causes. — Local  congestion 
of  the  uterus,  or  a  general  plethoric  state  of  the  patient,  have  often 
been  supposed  to  be  efficient  causes  of  recurring  abortion.  Dr.  Henry 
Bennet  has  especially  dwelt  on  the  influence  of  congestion  and  abra- 
sions of  the  cervix  in  causing  premature  expulsion  of  the  foetus,'  and 
recommends  the  topical  application  of  nitrate  of  silver,  or  other 
caustics,  to  the  inflammatory  abrasions  existing  on  the  neck  of  the 
womb.  Formerly  venesection  was  a  favorite  remedy ;  and  many 
authors  have  recommended  the  local  abstraction  of  blood  by  leeches 
applied  to  the  groin,  or  round  the  anus,  or  even  to  the  cervix.  The 
influence  of  general  plethora  is  more  than  doubtful ;  and  although 
local  congestions  are,  probably,  much  more  effective  causes,  still  it 
would  seem  more  judicious  to  treat  them  by  rest,  and  local  sedatives, 
rather  than  by  topical  applications  which,  injudiciously  applied,  might 
produce  the  very  accident  they  were  intended  to  prevent. 

\_Advantayes  of  a  Pure  Atmos]?]iere. — In  one  plethoric  woman  who 
aborted  repeatedly  at  about  six  weeks  after  impregnation,  and  in 
whom  depletion  failed  and  opium  was  inadmissible  from  cerebral 
disturbance,  I  at  last  succeeded  in  saving  the  seventh  foetus.  The 
lady  was  somewhat  rheumatic,  and  subject  to  attacks  of  spasmodic 
asthma,  for  which  she  occasionally  went  to  a  dry  mountainous  region. 
Finding  her  pregnant  when  at  this  retreat,  I  kept  her  there  until  she 
had  long  passed  the  usual  time  for  aborting,  when  I  had  her  brought 
home.  During  the  period  from  the  third  to  the  eighth  month  she 
was  at  times  affected  with  uterine  pains,  when  she  was  kept  still  in 
bed  until  they  subsided.  In  the  eighth  and  ninth  months  there  was 
no  trouble,  and  she  was  delivered  at  the  full  period  of  gestation.. 
Before  the  sixth  abortion,  when  at  home,  I  had  succeeded  in  check- 
ing the  action  of  the  uterus  until  the  end  of  the  second  month,  but 

'  On  Inflammation  of  the  Uterus,  p.  432. 


244  PREGNANCY. 

with  the  effect  of  producing  such  extreme  prostration,  that  I  was 
glad  to  learn  that  the  foetus  had  been  expelled. — Ed.] 

The  position  of  the  uterus  should  be  carefully  investigated.  If  it 
be  found  to  be  retroflexed,  a  Avell-fitting  Hodge's  pessary  should  be 
applied,  so  as  to  support  it  until  it  has  completely  risen  out  of  the 
pelvis. 

Treatment  in  Cases  dependiyig  on  Syphilis. — The  possibility  of 
syphilitic  infection  should  always  be  inquired  into,  for  this  poison 
may  act  on  the  product  of  conception  long  after  all  appreciable 
traces  of  it  have  disappeared  from  the  infected  parent.  Should  there 
be  recurrent  abortions  in  a  patient  who  had  formerly  suffered  from 
syphilis,  or  whose  husband  had  at  any  time  contracted  the  disease, 
DO  time  should  be  lost  in  using  appropriate  anti-syphilitic  remedies, 
which  should  invariably  be  administered  both  to  the  husband  and 
wife.  Diday  especially  insists  that  in  such  cases  it  is  not  suihcient 
to  submit  the  fatlier  and  mother  to  a  mercurial  course  in  the  absence 
of  pregnancy,  but  that,  as  each  successive  impregnation  occurs,  the 
mother  should  again  commence  anti-syphilitic  treatment,  even  though 
she  has  no  visible  traces  of  the  disease.*  In  this  way  there  is  reason- 
able ground  for  hoping  that  infection  of  the  ovum  may  be  prevented. 
I  think,  too,  that  we  may  be  the  more  encouraged  to  persevere  in 
the  treatment  of  these  unfortunate  cases,  from  the  fact  that  the 
syphilitic  poison  tends  to  wear  itself  out.  I  have  seen  several  cases 
in  which  this  taint,  at  first  proiluced  early  abortion,  then  each  suc- 
cessive pregnancy  was  of  longer  duration,  ■until  eventually  a  living 
child  was  born. 

In  fatty  derjeneration  of  the  chorion  villi^  and  in  other  morbid  states 
of  the  placenta,  which  act  by  preventing  the  proper  nutrition  of  the 
foetus,  and  the  due  aeration  of  its  blood,  there  is  no  reliable  means 
of  treatment  except  the  general  improvement  of  the  mother's  health. 
Simpson  strongly  recommended  the  administration  of  chlorate  of 
potash  in  cases  in  which  the  child  habitually  dies  in  the  latter 
months  of  pregnancy,  on  the  supposition  that  it  supplied  to  the  blood 
a  large  amount  of  oxygen,  and  thus  made  up  for  any  deficiency  in 
the  supply  of  that  element  through  the  placental  tufts.  The  theory 
is,  at  best,  a  doubtful  one,  although  I  believe  the  drug  to  be  unques- 
tionably beneficial  in  cases  of  the  kind.  It  probably  acts  by  its  tonic 
properties  rather  than  in  the  manner  Simpson  supposed.  It  may  be 
given  in  doses  of  15  to  20  grains  three  times  a  day,  and  may  be 
advantageously  combined  with  small  doses  of  dilute  hydrochloric 
acid.  In  frequently  recurring  premature  labors  with  dead  children, 
Simpson  strongly  recommended  the  induction  of  premature  labor  a 
little  before  the  time  at  which  we  had  reason  to  believe  that  the 
foetus  has  usually  perished  ;  or,  in  other  words,  before  the  placental 
disease  had  advanced  sufficiently  far  to  interfere  with  its  nutrition. 
The  practice  has  constantly  been  adopted  with  success,  and  is  per- 
fectly legitimate,  but  the  difficulty,  of  course,  is  to  fix  on  the  right 
time.     Careful  auscultation  of  the  foetal  heart  may  be  of  some  use  in 

1  Diday,  Infantile  Syphilis,  Syd.  Soc.  Trans,  p.  207. 


ABORTION    AND    PREMATURE    LABOR.  245 

guiding  us  to  a  decision,  as  the  death  of  the  foetus  is  generally  pre- 
ceded for  some  days  by  irregular,  tumultuous,  and  intermittent 
action  of  the  heart. 

There  will  always  remain  a  certain  number  of  cases  in  which  no 
appreciable  cause  can  be  discovered.  Under  such  circumstances 
prolonged  rest,  at  least  until  the  time  has  passed  at  which  abortion 
formerly  took  place,  will  afford  the  best  chance  of  avoiding  a  recur- 
rence of  the  accident.  There  must  always  be  some  difficulty  in 
carrying  out  this  indication,  inasmuch  as  the  patient's  healtli  is  apt 
to  suffer  in  other  ways  from  the  confinement,  and  the  want  of  fresh 
air  and  exercise  which  it  entails.  The  strictness  with  which  rest 
should  be  insisted  on  must  vary  in  different  cases,  but  it  should  be 
specially  attended  to  at  what  would  have  been  the  menstrual  periods. 
At  these  times  the  patient  should  remain  in  bed  altogether;  at  others 
she  may  lie  on  a  sofa,  and,  if  circumstances  permit,  spend  part  of  the 
day,  at  least,  in  the  open  air.  Sexual  intercourse  should  be  pro- 
hibited. Should  actual  symptoms  of  abortion  come  on,  the  pre- 
ventive treatment,  already  indicated,  may  be  resorted  to.  Great 
care,  however,  should  be  used  in  prescribing  opiates  as  preventives, 
and  they  should  be  given  for  a  specified  time  only.  I  have  seen, 
more  than  once,  an  incurable  habit  of  opium-eating  originate  from 
the  incautious  and  too  long  continued  exhibition  of  the  drug  in  such 
cases. 

When  we  have  satisfied  ourselves  that  abortion  is  inevitable,  we 
must  proceed  to  employ  treatment  that  favors  the  expulsion  of  the 
ovum. 

Removal  of  the  Ovum  when  within  reach. — If  the  os  be  sufficiently 
dilated,  and  the  pains  strong,  we  may  find  the  ovum  separated  and 
protruding  from  the  os.  We  may  then  be  able  to  detach  it  by  the 
finger.  For  this  purpose  the  uterus  is  depressed  from  without  by 
the  left  hand,  while  an  endeavor  is  made  to  scoop  out  the  ovum  witli 
the  examining  finger.  If  it  be  out  of  reach,  and  yet  appears  de- 
tached, chloroform  should  be  administered,  the  whole  hand  intro- 
duced into  the  vagina,  and  the  finger  into  the  uterine  cavity.  The 
complete  detachment  of  the  ovum  can,  in  this  way,  be  far  more 
readily  and  safely  effected  than  by  using  any  of  the  many  ovum-for- 
ceps which  have  been  invented  for  the  purpose. 

Plugging  of  the  Vagina. — If  the  ovum  be  not  sufficiently  sepa- 
rated, or  the  OS  be  undilated,  means  must  be  taken  to  control  the 
hemorrhage  until  the  former  can  be  removed  or  expelled.  It  is  here 
that  plugging  of  the  vagina  finds  its  most  useful  application.  This 
may  be  done  in  various  ways.  That  most  usually  employed  is  filling 
the  vagina  with  a  tolerably  large  sponge,  in  the'^interstices  of  which 
the  blood  coagulates.  A  better  plan  is  to  soak  a  number  of  pledgets 
of  cotton-wool  in  water  and  tie  a  string  round  each.  The  vagina  can 
be  completely  and  effectively  packed  with  these;  and  this  is  best 
done  through  a  speculum.  Each  pledget  should  be  covered  with 
glycerine,  which  completely  prevents  the  offensive  odor  Avhich  other- 
wise always  arises.  The  pledgets  can  be  removed  by  traction  on  the 
strings,  but  if  these  are  not  used  much  pain  is  caused  in  getting  them 


246  PREGNANCY. 

out  of  the  vagina.  The  plug  should  never  be  left  in  for  more  than 
six  or  eight  hours,  after  which  a  fresh  one  may  be  inserted  if  neces- 
sary. Two  or  three  full  doses  of  the  liquid  extract  of  ergot,  of  5ss 
to  5j  each,  or  a  subcutaneous  injection  of  ergotine,  maj'  be  given 
while  the  ping  is  in  position.  The  plug  itself  is  a  strong  excitant  of 
uterine  action,  and  the  two  combined  often  effect  complete  detach- 
ment, so  that,  on  the  removal  of  the  tampon,  the  ovum  may  be  found 
lying  loose  in  the  os  uteri.  If  the  os  be  undilated  and  the  ovum  en- 
tirely out  of  reach,  the  former  may  be  opened  by  means  of  sponge  or 
laminaria  tents.  I  think  a  well  prepared  sponge  tent  the  most  ef- 
fectual, and  it  can  be  maintained  in  situ  by  a  vaginal  plug  below  it. 
It  also  acts  as  a  most  efficient  plug,  effectually  controlling  all  hemor- 
rhage. In  a  few  hours  it  opens  up  the  os  sufficiently  to  admit  the 
finger. 

Retention  of  the  Membranes. — The  most  troublesome  cases  are  those 
in  which  the  foetus  is  first  expelled,  and  the  placenta  and  membranes 
remain  in  utero.  As  long  as  this  is  the  case  the  patient  can  never  be 
considered  safe  from  the  occurrence  of  septicseraia.  Dr.  Priestlej'  has 
strongly  insisted  on  the  importance  of  removing  the  secundines  as 
soon  as  possible.  There  can  be  no  doubt  that  this  should  be  done 
whenever  it  is  feasible.  Cases,  however,  are  frequently  met  with  in 
which  any  forcible  attempt  at  removal  would  be  likely  to  prove  very 
hurtful,  and  in  Avhich  it  is  better  practice  to  control  hemorrhage  by 
the  plug  or  sponge  tent,  and  wait  until  the  placenta  is  detached, 
which  it  will  generally  be  in  a  day  or  two  at  most.  Under  such 
circumstances  fetor  and  decomposition  of  the  secundines  may  be  pre- 
vented by  intra- uterine  injections  of  diluted  Condy's  fluid.  Provided 
the  OS  be  sufficiently  patulous  to  prevent  the  collection  of  the  fluid 
in  the  uterine  cavity,  and  not  more  than  a  drachm  or  two  of  fluid  be 
injected  at  a  time,  so  as  simply  to  wash  away  and  disinfect  decom- 
posing detritus,  they  can  be  used  with  perfect  safety.  Sometimes  cases 
are  met  with  in  which  the  os  has  entirely  closed,  and  in  which  we  can 
only  suspect  the  retention  of  the  placenta  by  the  history  of  the  case, 
the  continuance  of  hemorrhage,  or  the  presence  of  a  fetid  discharge. 
Should  we  see  reason  to  suspect  this  the  os  must  be  dilated  with 
sponge  or  laminaria  tents,  and  the  uterine  cavity  thoroughly  explored 
"under  chloroform.  This  condition  of  things  is  far  from  uncommon 
in  women  who  have  not  had  medical  assistance  from  the  first,  and  it 
often  gives  rise  to  very  troublesome  and  anxious  symptoms.  It  has 
been  said  that  placentae  thus  retained  have  been  completely  absorbed, 
and  cases  of  the  kind  have  been  related  by  Naegele  and  Osiander. 
The  spontaneous  absorption,  however,  of  so  highly  organized  a  body 
as  the  placenta  would  be  a  phenomenon  of  the  most  remarkable 
character ;  and  it  seems  more  natural  to  suppose  that,  in  most  cases 
of  the  kind,  the  placenta  has  been  cast  off  without  the  knowledge  of 
the  patient.  Sometimes  the  placenta  never  becomes  entirely  de- 
tached, and,  retaining  organic  connection  with  the  uterine  walls, 
forms  what  has  been  called  a  '■placental poly 2:)us.''  This  may  produce 
secondary  hemorrhages,  in  the  same  way  as  an  ordinary  fibroid  poly- 
pus,    Barnes  recommends  the  removal  of  these  masses  by  means  of 


ABORTION  AND  PREMATURE  LABOR,  247 

the  wire  ^crascur.  Before  their  detection  the  os  uteri  must  be 
opened  up. 

Retentionin  utero  of  a  BliylUed  Ovum. — The  cases,  previously  alluded 
to,  m  which  an  ovum  has  perished  in  early  pregnancy  and  is  retained 
in  utero,  are  often  puzzling,  and  may  give  rise  to  serious  moral  and 
medico-legal  questions.  The  blighted  ovum  may  be  retained  for 
many  months,  the  outside  limit  according  to  McOlintock,^  by  whom 
the  subject  has  been  ably  discussed,  being  nine  months.  The  appear- 
ance of  the  ovum  when  thrown  oft'  will  give  no  reliable  clue  to  the 
length  of  time  which  has  elapsed  since  it  perished.  The  symp- 
toms are  often  very  obscure.  Generally  there  have  been  the  usual 
indications  of  pregnancy  which,  with  or  without  signs  of  impending 
miscarriage,  disappears  or  are  modified,  and  then  follows  a  period  of 
ill  health,  with  pelvic  uneasiness,  and  irregular  metrorrhagia,  which 
may  be  mistaken  for  menstruation.  Occasionally,  but  by  no  means 
necessarily,  there  is  a  fetid  discharge,  and  this  probably  exists  only 
when  the  membranes  have  broken,  and  air  has  access  to  the  ovum. 
In  some  cases  obscure  septiceemic  symptoms  have  been  observed. 
Such  symptoms  are  obviously  too  indefinite  to  lead  to  an  accurate 
diagnosis.  In  the  course  of  time  the  ovum  is  generally  thrown  off', 
with  more  or  less  hemorrhage.  If  the  nature  of  the  case  is  detected 
ergot  may  be  given  to  promote  the  expulsion  of  the  uterine  contents, 
and  it  may  even  be  advisable  to  dilate  the  cervix  with  sponge  or 
laminaria  tents,  and  remove  them  artificially. 

Sahsequent  Management. — The  frequency  with  which  abortion  leads 
to  chronic  uterine  disease  should  lead  us  to  attach  much  more  im- 
portance to  the  subsequent  management  of  the  patient  than  has  been 
customary.  The  usual  practice  is  to  confine  the  patient  to  bed  for 
two  or  three  days  only,  and  then  to  allow  her  to  resume  her  ordinary 
avocations,  on  the  supposition  that  a  miscarriage  requires  less  sub- 
sequent care  than  a  confinement.  The  contrary  of  this  is,  however, 
most  probably  the  case ;  for  the  uterus  has  been  emptied  when  it  is 
unprepared  for  involution,  and  that  process  is  often  very  imperfectly 
performed.  We  should,  therefore,  insist  on  at  least  as  much  atten- 
tion being  paid  to  rest  as  after  labor  at  term. 

1  Sydenham  Society's  edition  of  Smellie's  Midwifery,  vol.  i.  p.  169. 


PAET  III. 

LABOR. 


CHAPTER   I. 

THE    PHENOMENA    OF   LABOR. 

Delivery  at  Term. — In  considering  delivery  at  term  we  have  to  dis- 
cuss two  distinct  classes  of  events. 

One  of  these  is  the  series  of  vital  actions  brought  into  play  in 
order  to  effect  the  expulsion  of  the  child ;  and  the  other  consists  of 
the  movements  imparted  to  the  child — the  body  to  be  expelled — in 
other  words,  the  mechanism  of  delivery. 

Causes  of  Lahor. — Before  proceeding  to  the  consideration  of  these 
important  topics,  a  few  words  may  be  said  as  to  the  determining 
causes  of  labor.  This  subject  has  been  from  the  earliest  times  a 
qusestio  vexata  among  physiologists  ;  and  many  and  varions  are  the 
theories  which  have  been  broached  to  explain  the  curious  fact  that 
labor  spontaneously  commences,  if  not  at  a  fixed  epoch,  at  anv  rate 
approximately  so.  It  must  be  admitted  that,  even  yet,  there  is  no 
explanation  which  can  be  implicitly  accepted. 

Foetal  or  Maternal  Causes. — The  explanations  Avhich  have  been 
given  may  be  divided  into  two  classes — those  whicli  attribute  the 
advent  of  labor  to  the  foetus,  and  those  which  refer  it  to  some  change 
connected  with  the  maternal  generative  organs. 

The  former  is  the  opinion  which  was  held  by  the  older  accou- 
cheurs, who  assigned  to  the  foetus  some  active  influence  in  effecting 
its  own  expulsion.  It  need  hardly  be  said  that  such  fanciful  views 
have  no  kind  of  physiological  basis.  Others  have  supposed  that 
there  might  be  some  change  in  the  placental  circulation,  or  in  the 
vascular  system  of  the  foetus,  which  might  solve  the  mystery.  The 
latest  hypothesis  of  this  kind,  which,  however,  is  not  fortified  by  any 
evidence,  is  by  Barnes,  who  savs :  "I  rather  incline  to  the  opinion 
that  when  the  foetus  has  attained  its  full  development,  when  its 
organs  are  prepared  for  external  life,  some  change  takes  piace  in  its 
circulation,  which  involves  a  correlative  disturbance  in  the  maternal 
circulation,  which  excites  the  attempt  at  labor."^ 

The  majority  of  obstetricians,  however,  refer  the  advent  of  labor 
to  purely  maternal  causes.  Among  the  more  favorite  theories  is  one, 
which  was  originally  started   in  this   country  by  Dr.    Power,  and 

•  Diseases  of  Women,  p.  434. 

(  248 ) 


THE  PHENOMENA  OF  LABOR.  249 

adopted  and  illustrated  by  Dcpaul,  Dubois,  and  other  writers.  It  is 
based  on  the  assumption  that  there  is  a  sphincter  action  of  the  libres 
of  the  cervix,  analogous  to  that  of  the  sphincters  of  the  bladder  and 
rectum,  and  that  Avlien  the  cervix  is  taken  up  into  the  general 
uterine  cavity  as  pregnancy  advances,  the  ovum  presses  upon  it,  irri- 
tates its  nerves,  and  so  sets  up  reflex  action,  which  ends  in  the  estab- 
lishment of  uterine  contraction.  This  theory  was  founded  on  erro- 
neous conceptions  of  the  changes  that  occurred  in  the  neck  of  the 
uterus;  and,  as  it  is  certain  that  obliteration  of  the  cervix  does  not 
really  take  place  in  the  manner  that  Power  believed  when  his  theory 
was  broached,  it  is  obvious  that  its  supposed  result  cannot  follow. 

Distension  of  the  Uterus. — Extreme  distension  of  the  uterus  has 
been  held  to  be  the  determining  cause  of  labor,  a  view  lately  revived 
by  Dr.  King,  of  Washington,*  who  believes  that  contractions  are  in- 
duced because  tlie  uterus  ceases  to  augment  in  capacity,  while  its 
contents  still  continue  to  increase.  This  hypothesis  is  sufficiently 
disproved  by  a  number  of  clinical  facts  which  show  that  the  uterus 
may  be  subject  to  excessive  and  even  rapid  distension — as  in  cases 
of  hydramnios,  multiple  pregnancy,  and  hydatiforra  degeneration  of 
the  ovum — without  the  supervention  of  uterine  contractions. 

Fatty  Degeneration  of  the  Decidua. — Another  inciter  of  uterine 
action  has  been  supposed  to  be  the  separation  of  the  ovum  from  its 
connections  to  the  uterine  parietes,  in  consequence  of  fatty  degenera- 
tion of  the  decidua  occurring  at  the  end  of  pregnancy.  The  sup- 
posed result  of  this  change,  which  undoubtedly  occurs,  is  that  the 
ovum  becomes  so  detaclied  from  its  organic  adhesions  as  to  be  some- 
what in  the  position  of  a  foreign  body,  and  thus  incites  the  nerves  so 
largely  distributed  over  the  interior  of  the  uterus.  This  theorj^, 
which  has  been  widely  accepted,  was  originally  started  by  Sir  James 
Simpson,  who  pointed  out  that  some  of  tlie  most  efficient  means  of 
inducing  labor  (such,  for  example,  as  the  insertion  of  a  gum-elastic 
catheter  between  the  ovum  and  the  uterine  walls)  probably  act  in 
the  same  way,  viz.,  by  effecting  separation  of  the  membranes  and 
detachment  of  the  ovum. 

Barnes  instances,  in  opposition  to  tbis  idea,  the  fact  that  ineffisct- 
ual  attempts  at  labor  come  on  at  the  natural  term  of  gestation  in 
cases  of  extra-uterine  pregnancy,  when  the  foetus  is  altogether  inde- 
pendent of  the  uterus,  and  therefore,  he  argues,  the  cause  cannot  be 
situated  in  the  uterus  itself.  A  fair  answer  to  this  argument  would 
be  that  although,  in  such  cases,  the  womb  does  not  contain  the  ovum, 
it  does  contain  a  decidua,  the  degeneration  and  separation  of  whicli 
might  suffice  to  induce  the  abortive  and  partial  attempts  at  labor 
then  witnessed. 

Objections  to  these  Theories. — A  serious  objection  to  all  these  theories, 
which  are  based  on  the  assumption  that  some  local  irritation  brings 
on  contraction,  is  the  fact,  which  has  not  been  generally  appreciated, 
that  uterine  contractions  are  always  present  during'  pregnancy  as  a 

'  American  Journal  of  Obstetrics,  vol.  iii. 
17 


250  LABOR. 

normal  occurrence,  and  that  they  may  be,  and  often  are.  readily  in- 
tensified at  any  time,  so  as  to  result  in  premature  delivery. 

It  is,  indeed,  most  likely  that,  at  or  about  the  full  term,  the  ner- 
vous supply  of  the  uterus  is  so  highly  developed,  and  in  so  advanced 
a  state  of  irritability,  that  it  more  readily  responds  to  stimuli  than 
at  other  times.  If  by  separation  of  the  decidua,  or  in  some  other 
way,  stimulation  of  the  excitor  nerves  is  then  effected,  more  frequent 
and  forcible  contractions  than  usual  may  result,  and,  as  they  become 
stronger  and  more  regular,  terminate  in  labor.  But,  allowing  this, 
it  still  remains  quite  unexplained  why  this  should  occur  with  such 
regularity  at  a  definite  time. 

Tyler  Smitli's  Ovarian  Theory. — Tyler  Smith  tried,  indeed,  to  prove 
that  labor  came  on  naturally  at  what  would  have  been  a  menstrual 
epoch,  the  congestion  attending  the  menstrual  nisus  acting  as  the  ex- 
citer of  uterine  contraction.  He,  therefore,  refers  the  onset  of  labor 
to  ovarian,  rather  than  to  uterine,  causes.  Although  this  view  is 
upheld  with  all  its  author's  great  talent,  there  are  several  objections 
to  it  difficult  to  overcome.  Thus,  it  assumes  that  the  periodic  changes 
in  the  ovary  continue  during  pregnancy,  of  which  there  is  no  proof. 
Indeed  there  is  good  reason  to  believe  that  ovulation  is  suspended 
during  gestation,  and  with  it,  of  course,  the  menstrual  nisus.  Be- 
sides, as  has  been  well  objected  by  Cazeaux,  even  if  this  theory  were 
admitted,  it  would  still  leave  the  mystery  unsolved,  for  it  would  not 
explain  why  the  menstrual  nisus  should  act  in  this  way  at  the  tenth 
menstrual  epoch,  rather  than  at  the  ninth  or  eleventh. 

In  spite,  then  of  the  many  theories  at  our  disposal,  it  is  to  be 
feared  that  we  must  admit  ourselves  to  be  still  in  entire  ignorance 
of  the  reason  why  labor  should  come  on  at  a  fixed  epoch. 

Mode  in  which  the  Expulsion  of  the  Child  is  effected. — -The  expulsion 
of  the  child  is  effected  by  the  contractions  of  the  muscular  fibres  of 
the  uterus,  aided  by  those  of  some  of  the  abdominal  muscles.  These 
efforts  are  in  the  main  entirely  independent  of  volition.  So  far  as 
regards  the  uterine  contractions,  this  is  absolutely  true,  for  the 
mother  has  no  power  of  originating,  lessening,  or  increasing  the 
action  of  the  uterus.  As  regards  the  abdominal  muscles,  however, 
the  mother  is  certainly  able  to  bring  them  into  action,  and  to  increase 
their  power  by  voluntary  efforts  ;  but,  as  labor  advances,  and  as  the 
head  passes  into  the  vagina  and  irritates  the  nerves  supplying  it,  the 
abdominal  muscles  are  often  stimulated  to  contract,  through  the  influ- 
ence of  reflex  action,  independently  of  volition  on  the  part  of  the 
mother. 

Tlie  Chief  Factor  in  Expulsion. — There  can  be  little  doubt  that  the 
chief  agent  in  the  expulsion  of  the  child  is  the  contraction  of  the 
uterus  itself.  This  opinion  is  almost  unanimously  held  by  accouch- 
eurs, and  the  influence  of  the  abdominal  muscles  is  believed  to  be 
purely  accessory.  Dr.  Haughton,  however,  maintains  a  view  which 
is  directly  contrary  to  this.  From  an  examination  of  the  force  of 
the  uterine  contractions,  arrived  at  by  measuring  the  amount  of  mus- 
cular fibre  contained  in  the  walls  of  the  uterus,  he  arrives  at  the 
conclusicm  that  the  uterine  contractions  are  chiefly  influential  in  rup- 


THE  PHENOMENA  OF  LABOR.  251 

taring  the  membranes,  and  dilating  the  os  uteri,  bringing  into  action, 
if  needful,  a  force  equivalent  to  54  lbs. ;  but  when  this  is  effected, 
and  the  second  stage  of  labor  has  commenced,  he  thinks  the  remain- 
der of  the  labor  is  mainly  completed  by  the  contractions  of  the  ab- 
dominal muscles,  to  which  he  attributes  enormous  powers,  equiva- 
lent, if  needful,  to  a  pressure  of  523.65  lbs,  on  the  area  of  the  pelvic 
canal. 

These  views  bear  on  a  topic  of  primary  consequence  in  the  phy- 
siology of  labor.  They  have  been  fully  criticized  by  Duncan,  who 
has  devoted  much  experimental  research  to  tlie  study  of  the  powers 
brought  into  action  in  the  expulsion  of  the  child.  His  conclusions 
are  that,  so  far  from  the  enormous  force  being  employed  that 
Haughton  estimated,  in  the  large  majority  of  cases  the  effective 
force  brought  to  bear  on  the  child  by  the  combined  action  of  both 
the  uterine  and  abdominal  muscles  is  less  than  50  lbs. — that  is,  less 
than  the  force  which  Haughton  attributed  to  the  uterus  alone.  In 
extremely  severe  labors,  when  the  resistance  is  excessive,  he  thinks 
that  extra  power  may  be  employed;  but  he  estimates  the  maximum 
as  not  above  80  lbs.,  including  in  this  total  the  action  of  both  the 
uterine  and  abdominal  muscles.  Joulin  arrived  at  the  conclusion 
that  the  uterine  contractions  were  capable  of  resisting  a  maximum 
force  of  about  one  hundred  weight.  Both  these  estimates,  it  will  be 
observed,  are  much  under  that  of  Haughton,  which  Duncan  de- 
scribes as  representing  "  a  strain  to  which  the  maternal  machinery 
could  not  be  subjected  without  instantaneous  and  utter  destruction." 

There  are  many  facts  in  the  history  of  parturition  which  make  it 
certain  that  the  chief  factor  in  the  expulsion  of  the  child  is  the 
uterus.  Among  these  may  be  mentioned  occasional  cases  in  which 
the  action  of  the  abdominal  muscles  is  materially  lessened,  if  not 
annulled — as  in  profound  antesthesia,  and  in  some  cases  of  para- 
plegia— in  which,  nevertheless,  uterine  contractions  suffice  to  affect 
delivery.  The  most  familiar  example  of  its  influence,  however, 
and  one  that  is  a  matter  of  everyday  observation  in  practice,  is 
when  inertia  of  the  uterus  exists.  In  such  cases  no  effort  on  the 
part  of  the  mother,  no  amount  of  voluntary  action  that  she  can 
bring  to  bear  on  the  child,  has  any  appreciable  influence  on  the 
progress  of  the  labor,  which  remains  in  abeyance  until  the  de- 
fective uterine  action  is  re-established,  or  until  artificial  aid  is 
given. 

The  contraction  of  the  uterus,  then,  being  the  main  agent  in  de- 
livery, it  is  important  for  us  to  appreciate  its  mode  of  action,  and  its 
effect  on  the  ovum. 

Uterine  Contractions  at  the  Com.'tnencern.ent  of  Lahor. — We  have 
seen  that  intermittent  and  generally  painless  uterine  contractions 
exist  during  pregnancy.  As  the  period  for  delivery  approaches, 
these  become  more  frequent  and  intense,  until  labor  actually  com- 
mences, when  they  begin  to  be  sufficiently  developed  to  effect  the 
opening  up  of  the  os  uteri,  with  the  view  to  the  passage  of  the 
child.  They  are  noAv  accompanied  by  pain,  which  increases  as  labor 
advances,  and  is  so  characteristic  that  ''pains"  are  universally  used 


252  LABOK. 

as  a  descriptive  term  for  the  contractions  themselves.  It  does  not 
necessarily  follow  that  uterine  contractions  are  painless  until  they 
commence  to  effect  dilatation  of  the  os  uteri.  On  the  contrary, 
during  the  last  days  or  even  weeks  of  pregnancy,  women  constantly 
have  irregular  contractions,  accompanied  by  severe  suffering,  which, 
however,  pass  off'  without  producing  any  marked  effect  on  the  cer- 
vix. When  labor  has  actually  begun,  if  the  hand  is  placed  on  the 
uterus,  when  a  pain  commences,  the  contraction  of  its  muscular 
tissue  is  very  apparent,  and  the  whole  organ  is  observed  to  become 
tense  and  hard,  the  rigidity  increasing  until  the  pain  has  reached  its 
acme,  the  uterine  walls  then  relaxing,  and  remaining  soft  until  the 
next  pain  comes  on.  At  the  commencement  of  labor  these  pains  are 
few,  separated  from  each  other  by  a  considerable  interval,  and  of 
short  duration.  In  a  perfectly  typical  labor  the  interval  between  the 
pains  becomes  shorter  and  shorter,  while,  at  the  same  time,  the  dura- 
tion of  each  pain  is  increased.  At  first  they  may  occur  only  once  in 
an  hour  or  more,  while  eventually  there  may  not  be  more  than  a  few 
minutes'  interval  between  them. 

Mode  in  v:hich  Dilatation  of  the  Cervix  is  Effected.- — If,  when  the 
pains  are  fairly  established,  a  vaginal  examination  be  made,  the  os 
uteri  will  be  found  to  be  thinned  and  dilated  in  proportion  to  the 
progress  of  the  labor.  During  the  contraction  the  bag  of  membranes 
will  be  felt  to  bulge,  to  become  tense  from  the  downward  pressure 
of  the  liquor  am  nil  within  it,  and  to  protrude  through  the  os  if  it 
be  sufficiently  open.  The  membranes,  with  the  contained  liquor 
aranii,  thus  form  a  fluid  wedge,  which  has  a  most  important  influence 
in  dilating  the  os  uteri  (see  Frontispiece).  This  does  not,  however, 
form  the  sole  mechanism  by  which  the  os  uteri  is  dilated,  for  it  is 
also  acted  upon  by  the  contractions  of  the  muscular  fibres  of  the 
uterus,  which  tend  to  pull  it  open.  It  is  probable  that  the  muscu- 
lar dilatation  of  the  os  is  effected  chiefly  by  the  longitudinal  fibres, 
which,  as  they  shorten,  act  upon  the  os  uteri,  the  part  where  there 
is  least  resistance. 

Partly  then  by  muscular  contraction,  partly  by  mechanical  pres- 
sure, the  cervical  canal  is  dilated,  and  as  it  opens  up  it  becomes  thin- 
ner and  thinner,  until  it  is  entirely  taken  up  into  the  uterine  cavity. 

Rupture  of  the  Membranes. — There  is  no  longer  any  obstacle  to  the 
passage  of  the  presenting  part  of  the  child  into  the  cavity  of  the 
pelvis,  and  the  force  of  the  pains  now  generally  effects  the  rupture 
of  the  membranes,  and  the  escape  of  the  liquor  am  nil.  There  is 
often  observed,  at  this  time,  a  temporary  relaxation  in  the  frequency 
of  the  pains,  which  had  been  steadily  increasing ;  but  they  soon  re- 
commence Avith  increased  vigor.  If  the  abdomen  be  now  examined 
it  will  be  ob?erved  to  be  much  diminished  in  size,  partly  in  conse- 
quence of  the  escape  of  the  liquor  amnii,  partly  from  the  descent  of 
the  foetus  into  the  pelvic  cavity. 

Change  in  the  Character  of  the  Pains. — The  character  of  the  pains 
soon  changes.  They  become  stronger,  longer  in  duration,  separated 
by  a  shorter  interval,  and  accompanied  by  a  distinct  forcing  effort, 
being  generally  described  as  "the  bearing-down"  pains.     Now  is  the 


THE  PHENOMENA  OF  LABOR.  253 

time  at  which  the  accessory  muscles  of  parturition  come  into  opera- 
tion. The  patient  brings  them  into  play  in  the  manner  which  will 
be  subsequently  described,  and  the  combined  action  of  the  uterine 
and  abdominal  muscles  continues  until  the  expulsion  of  the  child  is 
effected. 

Mode  of  Action  of  the  Uterus. — The  precise  mode  of  uterine  con- 
traction is  still  somewhat  a  matter  of  dispute.  It  is  generally  de- 
scribed as  commencing  in  the  cervix,  passing  gradually  upwards  by 
peristaltic  action,  the  wave  then  returning  downwards  towards  the 
OS  uteri.  This  view  was  maintained  by  AVigand,  and  has  been  en- 
dorsed by  Rigby,  Tyler  Smith,  and  many  otlier  writers.  In  support 
of  it  they  instance  the  fact  that,  on  the  accession  of  a  pain,  the  pre- 
senting part  first  recedes,  the  bag  of  membranes  then  becomes  tense 
and  protrudes  through  the  os,  and  it  is  not  until  some  time  that  the 
presenting  part  of  the  child  itself  is  pushed  down.  It  is  very  doubt- 
ful if  this  view  is  correct;  and  a  careful  examination  of  the  course 
of  the  pains  would  rather  lead  to  the  belief  that  the  contractions 
commence  at  the  fundus,  where  the  muscular  tissue  is  most  lai'gely 
developed,  and  gradually  proceed  downwards  to  the  cervix ;  the 
waves  of  contraction  being,  however,  so  rapid  that  the  whole  organ 
seems  to  harden  en  ma,ise.  The  apparent  recession  of  the  presenting 
part,  and  the  bulging  of  the  bag  of  membranes,  are  certainly  no 
proof  that  the  contractions  begin  at  the  cervix  ;  for  the  commencing 
contraction  would  necessarily  push  down  the  fluid  in  front  of  the 
head,  and  cause  the  membranes  to  bulge,  and  the  os  to  become  tense, 
before  its  force  was  brought  to  bear  on  the  foetus  itself.  Indeed  did 
the  contraction  commence  at  the  lower  part  of  the  uterus,  we  should 
expect  the  opposite  of  what  takes  place  to  occur,  and  the  waters  to 
be  pushed  upwards,  and  away  from  the  cervix.  The  fundal  origin 
of  the  contraction  is  further  illustrated  by  what  is  observed  when 
the  hand  of  the  accoucheur  is  placed  in  the  uterine  cavity,  as  often 
happens  in  certain  cases  of  hemorrhage  or  turning ;  for  if  a  pain 
then  comes  on,  it  will  be  felt  to  start  at  the  fundus,  and  gradually 
compress  the  hand  from  above  downwards. 

Value  of  the  Intermittent  Character  of  the  Pains. — The  intermittent 
character  of  the  contractions  is  of  great  practical  importance.  Were 
they  continuous,  not  only  would  the  muscular  powers  of  the  patient 
be  rapidly  exhausted,  but,  by  the  obliteration  of  the  vessels  produced 
by  the  muscular  contraction,  the  circulation  through  the  placenta 
would  be  interfered  with,  and  the  life  of  the  child  imperilled.  Hence 
one  of  the  chief  dangers  of  protracted  labor,  especially  after  the  es- 
cape of  the  liquor  amnii,  is  that  the  uterine  fibres  may  enter  into  a 
state  of  tonic  rigidity,  a  condition  that  cannot  be  long  continued 
without  serious  risks  both  to  the  mother  and  child. 

The  fact  that  the  uterine  contracti(ms  are  altogether  involuntary 
proves  them  to  be  excited — as  indeed  we  would  ct  priori  infer  from 
our  knowledge  of  the  anatomical  arrangement  of  the  nerves  of  the 
uterus — solel  V  by  the  sympathetic  system.  Still  it  is  a  fact  of  every- 
day observation  that  they  can  be  largely  influenced  by  emotions. 
Various  stimuli  applied  to  the  spinal  system  of  nerves  (as  for  exam- 


25-4  LABOR, 

pie  when  the  mammgs  are  irritated)  have  also  a  marked  effect  in  in- 
ducing uterine  contraction.  The  precise  mode  in  which  such  influ- 
ence is  conveyed  to  the  uterus,  in  spite  of  the  numerous  experiments 
which  have  been  made  for  the  purpose  of  determining  how  far  labor 
is  affected  by  destruction  of  the  spinal  cord,  is  still  a  matter  of  doubt. 
After  the  foetus  has  passed  through  the  cervix,  the  spinal  nerves 
distributed  to  the  vagina  and  perineum  are  excited  by  the  pressure 
of  the  presenting  part,  and  through  them,  the  accessory  powers  of 
parturition  are  chiefly  brought  into  play.  The  contraction  of  the 
muscles  of  the  vagina  itself  is  supposed  to  have  some  influence  in 
favoring  the  expulsion  of  the  foetus  after  the  birth  of  part  of  the 
body,  and  also  in  promoting  the  expulsion  of  the  placenta.  In  the 
lower  animals  the  vagina  has  a  very  marked  contractile  property, 
and  is,  in  some  of  them,  the  main  agent  by  which  the  young  are  ex- 
pelled. In  the  human  subject  this  influence  is  certainly  of  very 
secondary  importance. 

Character  and  Source  of  Pains  during  Labor. — The  amount  of  suf- 
fering experienced  during  labor  varies  much  in  different  cases,  and 
is  in  direct  proportion  to  the  nervous  susceptibility  of  the  patient. 
There  are  some  women  who  go  through  labor  with  little  or  no  pain 
at  all.  This  is  proved  by  the  cases  (of  which  there  are  numerous 
authentic  instances  recorded)  in  which  labor  has  commenced  during 
sleep,  and  the  child  has  been  actually  born  without  the  mother 
awaking.  I  am  acquainted  with  a  lady,  who  has  had  a  large  family, 
who  assures  me  that,  though  the  labor  is  accompanied  by  a  sense  of 
pressure  and  discomfort,  she  experiences  nothing  which  can  be  called 
actual  pain.  Such  a  happy  state  of  affairs  is,  however,  extremely 
exceptional,  and,  in  the  vast  majority  of  cases,  parturition  is  accom- 
panied by  intense  suffering  during  its  whole  course,  in  some  cases 
amounting  to  anguish,  which  has  probably  no  parallel  under  any 
other  condition. 

The  precise  cause  of  the  pain  has  been  much  discussed,  and  is,  no 
doubt,  complex. 

In  the  First  Stage. — In  the  early  stage  of  labor,  and  before  the  di- 
latation of  the  OS,  it  is  chiefly  seated  in  the  back,  from  whence  it 
shoots  round  the  loins  and  down  the  thighs.  It  is  then  probably  pro- 
duced, partly  by  pressure  on  the  nerve  filaments  caused  by  contrac- 
tion of  the  muscular  fibres  to  which  they  are  distributed,  and  partly 
by  stretching  and  dilatation  of  the  muscular  tissue  of  the  cervix.  M. 
Beau  believes  that  in  this  stage  the  pain  is  not  produced,  strictly 
speaking,  in  the  uterus  itself,  but  is  rather  a  neuralgia  of  the  lumbo- 
abdominal  nerves.  The  pains  at  this  time  are  generally  described 
as  "  acute"  and  "  grinding,"  terms  which  sufficiently  well  express 
their  nature.  In  highly  nervous  women  these  pains  are  often  much 
less  well  borne  than  those  of  a  later  stage,  and  the  suffering  they 
undergo  is  indicated  by  their  extreme  restlessness  and  loud  cries 
as  each  contraction  supervenes.  As  the  os  dilates,  and  the  labor 
advances  into  the  expulsive  stage,  other  sources  of  suffering  are  added. 

In  the  Second  Stage. — The  presenting  part  now  passes  into  the  va- 
gina and  presses  on  the  vaginal  nerves,  as  well  as  on  the  large  ner- 


THE  PHENOMENA  OF  LABOR.  255 

vous  plexuses  lying  in  tlie  pelvis.  As  it  descends  lower  it  stretches 
the  perineum  and  vulva,  and  presses  on  the  bladder  and  rectum, 
lience  cramps  are  produced  in  the  muscles  supplied  by  the  nerve 
plexuses,  as  well  as  an  intolerable  sense  of  tearing  and  stretching  in 
the  vulva  and  perineum,  and  often  a  distressing  ieeling  of  tenesmus 
in  the  bowels.  By  this  time  the  accessory  muscles  of  parturition  are 
brought  into  action,  and  they,  as  well  as  the  uterine  muscles,  are 
thrown  into  frequent  and  violent  contractions,  which,  independently 
of  the  other  causes  mentioned,  are  sufficient  of  themselves  to  produce 
great  ]^ain,  likened  to  that  of  colic,  produced  by  involuntary  and 
repeated  contraction  of  the  muscles  of  the  intestines. 

Taking  all  these  causes  into  consideration,  there  is  no  lack  of  suf- 
ficient explanation  of  the  intolerable  suffering  which  is  so  constant 
an  accompaniment  of  child-birth. 

Effect  of  the  Pairis  on  the  Mother  and  Foetus. — The  effect  of  the  pains 
on  the  mother's  circulation  is  well  marked.  The  rapidity  of  the  pulse 
increases  distinctly  with  each  contraction,  and,  as  the  pain  passes 
off,  it  again  declines  to  its  former  state.  A  similar  observation  has 
been  made  with  regard  to  the  sounds  of  the  foetal  heart,  especially 
after  the  expulsion  of  the  liquor  amnii.  Hicks  has  pointed  out  that 
during  a  pain  the  muscular  vibrations  give  rise  to  a  sound  which 
often  resembles  that  of  the  foetal  heart,  and  which  completely  disap- 
pears when  the  muscular  tissue  relaxes.  The  effect  of  the  pain  m 
intensifying  the  uterine  souffle  has  been  already  mentioned.  The 
strong  muscular  efforts  would  naturally  lead  us  to  expect  a  marked 
elevation  of  temperature  during  labor.  Further  observations  on  this 
point  are  required;  but  Squire  asserts  that  there  is  generally  only  a 
very  slight  increase  in  temperature  during  delivery,  rapidly  passing 
off  as  soon  as  labor  is  over. 

Division  of  Labor  into  Stages. — Such  being  the  physiological  facts 
in  connection  with  the  labor  pains,  we  may  now  describe  the  ordinary 
progress  of  a  natiiral  labor — ^that  is,  one  terminated  by  the  natural 
powers,  and  with  a  head  presenting. 

For  facility  of  description  obstetricians  have  long  been  in  the  habit 
of  dividing  the  course  of  labor  into  stages,  which  correspond  pretty 
accurately  with  the  natural  sequence  of  events.  For  this  purpose 
we  generally  talk  of  three  stages :  viz.,  1,  from  the  commencement 
of  regular  pains  until  the  complete  dilatation  of  the  cervix ;  2,  from 
the  complete  dilatation  of  the  cervix  until  the  expulsion  of  the  child; 
3,  the  concluding  stage,  comprising  the  permanent  contraction  of  the 
uterus,  and  the  separation  and  expulsion  of  the  placenta.  To  these 
we  may  conveniently  add  a  preparatory  stage,  antecedent  to  the 
regular  commencement  of  the  labor. 

Pre-paratory  Stage. — For  a  short  time  before  delivery,  varying  from 
a  few  days  to  a  week  or  two,  certain  premonitory  symptoms  gene- 
rally exist,  which  indicate  the  approaching  advent  of  labor.  Some- 
times they  are  well  marked,  and  cannot  be  mistaken;  at  others  they 
are  so  slight  as  to  escape  observation.  Amongst  the  most  common 
is  a  sinking  of  the  uterus  into  the  pelvic  cavity,  resulting  from  the 
relaxation  of  the  soft  parts  preceding  delivery..     The  result  is,  that 


256  LABOR. 

the  upper  edge  of  the  uterine  tumor  is  less  high  than  before,  and,  in 
consequence,  the  pressure  on  the  respiratory  organs  is  diminished, 
and  the  woman  often  feels  lighter,  and  altogether  less  unwieldy, 
than  in  the  previous  weeks.  If  a  vaginal  examination  be  made  at 
this  time,  the  lower  segment  of  the  uterus  will  be  found  to  have  sunk 
lower  into  the  pelvic  cavity;  and  the  consequence  of  this  is  that, 
while  the  respiration  is  less  embarrassed,  and  the  patient  feels  less 
bulky,  other  accompaniments  of  pregnancy,  such  as  hemorrhoids, 
irritability  of  the  bladder  and  bowels,  and  oedema  of  the  limbs,  be- 
come aggravated.  The  increased  pressure  on  the  bowels  often  induces 
a  sort  of  temporary  diarrhoea,  which  is  so  far  advantageous  that  it 
empties  the  bowels  of  feces  wdiicli  may  have  collected  within  them. 
As  has  already  been  pointed  out,  the  contractions  which  have  been 
going  on  at  intervals  during  the  latter  mouths  of  pregnancy  now  get 
more  and  more  marked,  and  they  have  the  effect  of  producing  a  real 
shortening  of  the  cervix,  which  is  of  great  value  preparatory  to  its 
dilatation.  More  marked  mucous  discharge  from  the  cavity  of  the 
cervix  also  generally  occurs  a  short  time  before  labor,  and  it  is  not 
infrequently  tinged  with  blood  from  the  laceration  of  minute  capillary 
vessels.  This  discharge,  popularly  known  as  the  "s/^oi6'5,"  is  a  pretty 
sure  sign  that  labor  is  not  far  oft".  It  may,  however,  be  entirely 
absent,  even  until  the  birth  of  the  child.  When  copious  it  serves  to 
lubricate  the  passages,  and  is  generally  coincident  with  rapid  dilata- 
tion of  the  parts,  and  a  speedy  labor. 

False  Pains. — During  this  time  (premonitory  stage)  painful  uterine 
contractions  are  often  present,  which,  however,  have  no  effect  in 
dilating  the  cervix.  In  some  cases  they  are  frequent  and  severe, 
and  are  very  apt  to  be  mistaken  for  the  commencement  of  real  labor. 
Such  '■'■false  pains^''''  as  they  are  termed,  are  often  excited  and  kept 
up  by  local  irritations,  such  as  a  loaded  or  disordered  state  of  the  in- 
testinal canal ;  and  they  frequently  give  rise  to  considerable  distress, 
and  much  inconvenience  both  to  the  patient  and  practitioner.  They 
are,  it  should  be  remembered,  only  the  normal  contractions  of  the 
uterus,  intensified  and  accompanied  with  pain. 

First  Stage^  or  Dilatation. — As  labor  actually  commences,  the 
uterine  contractions  become  stronger,  and  the  fact  that  they  are 
"(;?-we"  pains  can  be  ascertained  by  their  effect  on  the  cervix.  If  a 
vaginal  examination  be  made  during  one  of  these,  the  membranes 
will  be  felt  to  become  tense  and  bulging  during  the  pain,  and  the  os 
uteri  will  be  found  partially  dilated,  and  thinned  at  its  edges.  As 
labor  advances  this  effect  on  the  os  becomes  more  and  more  marked. 
At  first  the  dilatation  is  very  slight,  perhaps  not  more  than  enough 
to  admit  the  tip  of  the  examining  finger,  and  both  the  upper  and 
lower  orifices  of  the  cervix  can  be  made  out.  As  the  pains  get 
stronger  and  more  frequent,  dilatation  proceeds  in  the  way  already 
described,  and  the  cervix  gets  more  thin  and  tense,  until  we  can  feel 
a  thin  circular  ring  (which  is  lax  between  the  pains,  but  becomes 
rigid  and  tense  during  the  contraction  when  the  bag  of  water  bulges 
through  it),  without  any  distinction  between  the  upper  and  lower 
orifices.     During  this  time  the  patient,  although  she  may  be  suffer- 


THE  PHENOMENA  OF  LABOR.  257 

ing  acutely,  is  generally  able  to  sit  up  and  walk  about.  The  amount 
of  pain  experienced  varies  much  according  to  the  character  of  the 
patient.  In  emotional  women  of  highly-developed  nervous  suscepti- 
bilities it  is  generally  very  great.  They  are  restless,  irritable,  and 
desponding,  and  when  the  pain  comes  on  cry  out  loudly.  The 
character  of  the  cry  is  peculiar  and  well  marked  during  the  first  stage 
and  has  constantly  been  described  by  obstetric  writers  as  charac- 
teristic. It  is  acute  and  high,  and  is  certainly  very  different  from 
the  deep  groans  of  the  second  stage,  when  the  breath  is  involuntarily 
retained  to  assist  the  parturient  effort.  When  dilatation  is  nearly 
completed  various  reflex  nervous  phenomena  often  show  themselves. 
One  of  these  is  nausea  and  vomiting,  another  is  uncontrollable 
shivering,  which  is  not  accompanied  by  a  sense  of  coldness,  the 
patient  being  often  hot  and  perspiring.  Both  these  symptoms  indi- 
cate that  the  propulsive  stage  will  shortly  commence;  and  they  may 
be  regarded  as  favorable  rather  than  otherwise,  although  they  are 
apt  to  alarm  the  patient  and  her  friends.  By  this  time  the  osis  fully 
dilated,  the  membranes  generally  rupture  spontaneously,  and  a  con- 
siderable portion  of  the  liquor  amnii  flows  away.  The  head,  if  pre- 
senting, often  acts  as  a  sort  of  ball-valve,  and,  falling  down  on  the 
aperture  of  the  cervix,  prevents  the  complete  evacuation  of  the 
liquor  amnii,  which  escapes  b}^  degrees  during  the  rest  of  the  labor, 
or  may  be  retained  in  considerable  quantity  until  the  birth  of  the 
child. 

It  not  infrequently  happens,  if  the  membranes  are  somewhat 
tougher  than  usual,  and  "the  pains  frequent  and  strong,  that  the 
foetus  is  pushed  through  the  pelvis,  and  even  expelled,  surrounded 
by  the  membranes.  AVhen  this  occurs  the  child  is  said  to  be  born 
with  a  "  cav.l^''  and  this  event  would  doubtless  happen  more  fre- 
quently than  it  does,  were  it  not  the  custom  of  the  accoucheur  to 
rupture  the  membranes  artificially  as  soon  as  the  os  is  completely 
opened  up,  after  which  time  their  integrity  is  no  longer  of  any  value. 

Second  Staye^  or  Propulsion. — The  os  is  now  entirely  retracted  over 
the  presenting  part,  and  is  no  longer  to  be  felt,  the  vagina  and  the 
uterine  cavity  forming  a  single  canal.  Now  the  mucous  discharge  is 
generally  abundant,  so  that  the  examining  finger  brings  away  long 
strings  of  glairy  transparent  mucus,  tinged  with  blood.  The  pains 
after  a  short  interval  of  rest,  become  entirely  altered  in  character. 
The  uterus  contracts  tightly  round  the  foetus,  the  presenting  part  de- 
scends into  the  pelvis,  and  the  true  propulsive  pains  commence.  The 
accessory  muscles  of  parturition  now  come  into  play.  With  each 
pain  the  patient  takes  a  deep  inspiration,  and  thus  fills  the  chest,  so 
as  to  give  a,  jjoint  (Vapjyui  to  the  abdominal  muscles.  For  the  same 
reason  she  involuntarily  seizes  hold  of  some  point  of  support,  as  the 
hand  of  a  bystander  or  a  towel  tied  to  the  bed,  and,  at  the  same  time, 
pushes  with  her  feet  against  the  end  of  the  bed,  and  so  is  able  to 
bear  down  to  advantage.  The  cries  are  no  longer  sharp  and  loud, 
but  consist  of  a  series  of  deep  suppressed  groans,  which  correspond 
to  a  succession  of  short  expirations  made  during  the  straining  effort. 
In  this  way  the  abdominal  muscles  contract  forcibly  on  the  uterus. 


258  LABOR. 

which  they  further  stimulate  to  action  by  pressing  upon  it.  It  is  to 
be  observed  that  these  straining  efforts  are,  to  a  considerable  extent, 
under  the  control  of  the  patient.  By  encouraging  her  to  hold  her 
breath  and  bear  down  they  can  be  intensified;  while  if  we  wish  to 
lessen  them  we  can  advise  her  to  call  out,  and  when  she  does  so  the 
abdominal  muscles  have  no  longer  a  fixed  point  of  action.  Although 
the  patient  may  thus  lessen  the  effect  of  these  accessory  muscles,  it 
is  entirely  out  of  her  power  to  stop  their  action  altogether.  As  labor 
advances  the  head  descends  lower  and  lower,  receding  somewhat  in 
the  intervals  between  the  pains,  until  eventually  it  comes  down  in 
the  perineum,  which  it  soon  distends. 

Distension  of  the  Perineum  and  Birth  of  the  Child. — The  pains  now 
get  stronger  and  more  frequent,  often  with  scarcel}'"  a  perceptible  in- 
terval between  them,  until  the  perineum  gets  stretched  by  the  ad- 
vancing head.  In  the  interval  between  the  pains  elasticity  of  the 
perineal  structures  pushes  the  head  upwards,  so  as  to  diminish  the 
tension  to  which  the  perineum  is  subjected,  the  next  pain  again  put- 
ting it  on  the  stretch,  and  protruding  the  head  a  little  further  than 
before.  By  this  alternate  advance  and  recession,  the  gradual  yield- 
ing of  the  structures  is  favored,  and  risk  of  laceration  greatly  dimin- 
ished. During  this  time  the  pressure  of  the  head  mechanically 
empties  the  bowel  of  its  contents.  During  the  last  pains,  when  the 
perineum  is  stretched  to  the  utmost,  the  anal  aperture  is  dilated, 
sometimes  to  the  size  of  a  five-shilling  piece  ;  and  in  this  way  the 
perineum  is  relaxed,  just  as  the  distension,,  and  consequent  risk  of 
laceration,  are  at  their  maximum.  The  apex  of  the  head  now  pro- 
trudes more  and  more  through  the  vulva,  surrounded  b}^  the  orifice 
of  the  vagina,  and  eventually  it  glides  over  the  perineum  and  is 
expelled,  P'he  intensity  of  the  suffering  at  this  moment  generally 
causes  the  patient  to  call  out  loudly.  The  force  of  the  abdominal 
muscles  is  thus  lessened  at  the  last  moment,  and  this,  in  combination 
with  the  relaxation  of  the  sphincter  ani,  forms  an  admirable  con- 
trivance for  lessening  the  risk  of  perineal  injury.  The  rest  of  the 
body  is  generally  expelled  immediately  by  a  single  pain,  and  with  it 
are  discharged  the  remains  of  the  liquor  amnii,  and  some  blood-clots 
from  separation  of  the  placenta ;  and  so  the  second  stage  of  labor 
terminates. 

The  Third  Stage.  Its  Importance. — The  third  stage  commences 
after  the  expulsion  of  the  child.  It  is  of  paramount  importance  to 
the  safety  of  the  mother  that  it  should  be  conducted  in  a  natural 
and  efficient  manner  ;  for  it  is  now  that  the  uterine  sinuses  are  closed, 
and  the  frail-  barrier  by  which  nature  effects  this  may  be  very  readily 
interfered  with,  and  serious  and  even  fatal  loss  of  blood  ensue.  Un- 
fortunately, it  is  too  often  the  case  that  the  practitioner's  entire  at- 
tention is  fixed  on  the  expulsion  of  the  child,  so  that  the  natural 
history  of  the  rest  of  delivery  is  very  generally  imperfectly  studied 
and  understood. 

Contraction  of  the  Uterus  and  Detachment  of  the  Placenta. — As  soon 
as  the  child  is  expelled,  the  uterine  fibres  contract  in  all  directions, 
and  the  hand,  following  the  uterus  down,  will  find  that  it  forms  a 


THE    PHENOMENA    OF    LABOR. 


259 


Fig.  92. 


firm  rounded  mass  lying  in  the  lower  part  of  the  abdominal  cavity. 
By  retraction  of  its  internal  surface,  tiie  placental  attachments  are 
generally  ssparated,  and  the  after-birth  remains  in  the  cavity  of  the 
uterus  as  a  foreign  body. 

Mode  in  lohicli  Hemorrhage  is  Prevented. — The  escape  of  blood  from 
the  open  mouths  of  the  uterine  sinuses  is  now  prevented  in  two  ways; 
viz.,  (1)  by  the  contraction  of  the  uterine  walls,  and  the  more  firm, 
persistent,  and  tonic  this  is,  the  more  certain  is  the  immunity  from 
hemorrhage ;  (2)  by  the  formation  of  coagula  in  the  months  of  the 
vessels.  Any  undue  haste  in  promoting  the  expulsion  of  the  pla- 
centa tends  to  prevent  the  latter  of  these  two  hemostatic  safeguards, 
and  is  apt  to  be  followed  by  loss  of  blood.  After  a  certain  time, 
averaging  from  a  quarter  to  half  an  hour,  the  uterus  will  be  ielt  to 
harden,  and,  if  the  case  be  solely  left  to  nature,  what  has  been  aptly 
called  a  miniature  labor  occurs.  Pains  come  on,  and  the  placenta  is 
spontaneously  expelled  from  the  uterus,  either  into  the  canal  of  the 
vagina,  or  even  externally.  In  most  obstetric  works  it  is  stated  that 
the  after-birth  may  be  separated  either  from  its  centre  or  edge,  and 
that  it  is  very  generally  expelled  through  the  os 
in  an  inverted  form,  with  its  foetal  surface  down- 
wards, and  folded  transvarsely  on  itself.  That 
this  is  the  mode  in  which  the  placenta  is  often 
expelled,  when  traction  on  the  cord  is  practised, 
is  a  matter  of  certainty.  It  then  passes  through 
the  OS  very  much  in  the  shape  of  an  inverted 
umbrella.  It  is  certain,  however,  that  this  is 
not  the  natural  mechanism  of  its  delivery. 
What  this  is  has  been  well  illustrated  by  Dun- 
can,^ who  has  very  clearly  shown  that,  when  this 
stage  of  labor  is  left  entirely  to  nature,  the  sepa- 
rated placenta  is  expelled  edgeways,  its  uterine 
and  detached  surface  gliding  along  the  inner  sur- 
face of  the  uterus,  the  foldhigs  of  its  structure 
being  parallel  to  the  long  diameter  of  the  ute- 
rine cavity  (Fig.  92).  In  this  way  it  is  expelled 
into  the  vagina,  and  during  the  process  little  or 
no  hemorrhage  occurs.  Wnen  the  placenta  is 
drawn  out  in  the  way  too  generally  practised,  it 
obstructs  the  aperture  of  the  os,  and,  acting  like 
the  piston  of  a  pump,  tends  to  promote  hemorrhage.  The  corol- 
laries as  to  treatment  drawn  from  these  facts  will  be  subsequently 
considered.  I  am  anxious,  however,  here  to  direct  attention  to  na- 
ture's mechanism,  because  I  believe  there  is  no  part  of  labor  about 
the  management  of  which  erroneous  views  are  more  prevalent  than 
that  of  this  stage,  and  none  in  which  they  are  more  apt  to  lead  to 
serious  consequences;  and  unless  the  mode  in  which  nature  effects 
the  expulsion  of  the  placenta,  and  prevents  hemorrhage,  is  thoroughly 
understood,  we  shall  certainly  fail  in  assisting  her  in  a  proper  man- 


Mode  in  which  the  Placenta 

is  Naturally  Expelled. 

(After  Duncan.) 


>  Edin.  Med.  Jour.,  April,  1871. 


260  LABOR. 

ner.  In  the  large  proportion  of  cases,  Avhen  left  entirely  to  them- 
selves, the  placenta  would  be  retained,  if  not  in  the  uterus,  at  any  rate 
in  the  vagina,  for  a  considerable  time — possibly  for  several  hours — 
and  such  delay  would  very  unnecessarily  tire  the  patience  of  the 
practitioner,  and  be  prejudicial  to  the  patient.  It  is,  therefore,  our 
duty  in  the  majority  of  cases,  to  promote  the  expulsion  of  the  after- 
birth ;  and  when  this  is  properly  and  scientifically  done,  we  increase, 
rather  than  diminish  the  patient's  safety  and  comfort.  But,  in  order 
to  do  this,  we  must  assist  nature,  and  not  act  in  opposition  to  her 
method,  as  is  so  often  the  case. 

After-pains. — When  once  the  placenta  is  expelled,  the  uterus  con- 
tracts still  more  firmly,  and  in  a  typical  case,  is  felt  just  within  the 
pelvic  brim,  hard  and  firm,  and  about  the  size  of  a  cricket  ball. 
Generally  for  several  hours,  or  even  for  one  or  two  days,  it  occasion- 
ally relaxes  and  contracts,  and  these  contractions  give  rise  to  the 
"  after-pains''''  from  which  women  often  suffer  much.  The  object  of 
these  pains  is,  no  doubt,  to  expel  any  coagula  that  may  remain  in  the 
uterus,  and  therefore,  however  unpleasant  they  may  be  to  the  patient, 
they  must  be  considered,  unless  yqtj  excessive,  to  be  salutary  rather 
than  otherwise. 

Duration  of  Labor. — The  length  of  labor  varies  extremely  in  dif- 
ferent cases,  and  it  is  quite  impossible  to  lay  down  any  definite  rules 
with  regard  to  it.  Subject  to  exceptions,  labor  is  longer  in  primi- 
paree  than  in  multiparte,  on  account  of  the  greater  resistance  of  the 
soft  parts  in  the  former,  especially  of  the  structures  about  the  vagina 
and  vulva.  It  is  also  generally  stated  that  the  difficulty  of  labor 
increases  with  the  age  of  the  patient,  and  that  in  elderly  primiparas 
it  is  hkely  to  be  unusually  tedious  from  rigidity  of  the  soft  parts. 
It  is  very  doubtful  if  this  opinion  has  any  real  basis,  and  in  such 
cases  the  practitioner  often  finds  himself  agreeably  disappointed  on 
the  result.  Mr.  Eoper,^  indeed,  argues  that  the  wasting  of  the  tissues 
which  occurs  after  forty  years  of  age  diminishes  their  resistance,  and 
that  first  labors,  after  that  age,  are  easier,  as  a  rule,  than  in  early 
life.  The  habits  and  mode  of  life  of  patients  have,  no  doubt,  a  con- 
siderable influence  on  the  duration  of  labor,  but  we  are  not  in  pos- 
session of  any  very  reliable  facts  with  regard  to  this  subject.  It  is 
reasonable  to  suppose  that  the  tissues  of  large,  muscular,  strongly 
developed  women  will  offer  more  resistance  than  those  of  slighter 
build.  On  the  other  hand,  women  of  the  latter  class,  especially  in 
the  upper  ranks  of  life  more  often  develop  nervous  susceptibihties. 
which  may  be  expected  to  influence  the  length  of  their  labors.  The 
average  duration  of  labor,  calculated  from  a  large  number  of  cases, 
is  from  eight  to  ten  hours ;  even  in  primipar^e,  however,  it  is  con- 
stantlv  terminated  in  one  or  two  hours  from  its  commencement,  and 
may  be  extended  to  twenty-four  hours  without  any  symptoms  ot 
urgency  arising.  In  raultiparse  it  is  frequently  over  in  even  a  shorter 
time.  ^  Indications  calling  for  interference  may  arise  at  any  time 
during  the  progress  of  labor,  independently  of  its  length.     The  pro- 

i  Obst.  Trans.,  v.  7. 


DELIVERY  IN  HEAD  PRESENTATIONS.  261 

portion  between  the  length  of  the  first  and  second  stages  also  varies 
considerably.  The  lii'st  stage  is  generally  the  longest ;  and  it  is 
stated  by  Cazeaux  to  be  normally  about  twice  the  length  of  the 
second.  This  is  probably  under  the  mark,  and  I  believe  Joulin  to 
be  nearer  the  truth  in  stating  that  the  first  stage  should  be  to  the 
second  as  four  or  five  to  one,  rather  than  as  two  to  one.  Often  when 
the  first  stage  has  been  very  prolonged,  the  second  is  terminated 
rapidly. 

Necessity  of  Caution  in  expressinrj  an  O'pinion  as  to  the  jjossible 
Duration  of  labor. — -The  practitioner  is  constantly  asked  as  to  the 
probable  length  of  labor,  and  the  uncertainty  cf  this  should  always 
lead  him  to  give  a  most  guarded  opinion.  Even  when  labor  is  pro- 
gressing apparently  in  the  most  satisfactory  manner,  the  pains  fre- 
quently die  away,  and  delivery  may  be  delayed  for  many  hours.  In 
the  first  stage  a  cervix  that  is  apparently  rigid  and  unyielding  may 
rapidly  and  unexpectedl}/  dilate,  and  delivery  soon  follow.  In  either 
case,  if  the  practitioner  has  committed  himself  to  a  positive  opinion 
he  is  apt  to  incur  blame,  and  it  is  far  better  always  to  be  extremely 
cautious  in  our  predictions  on  this  point. 

Period  of  the  Bay  at  which  Labor  Occurs. — A  somewhat  larger  pro- 
portion of  deliveries  occur  in  the  early  hours  of  the  morning  than  at 
other  times.  Thus  West^  found  that  out  of  2019  deliveries,  780  took 
place  from  11  P.M.  to  7  A.M.,  662  from  7  A.M.  to  o  P.M.,  and  577 
from  3  P.M.  to  11  P.M. 


CHAPTEE    II. 

MECHAmSM    OF    DELIVERY   IN"   HEAD   PRESENTATIONS. 

Importance  of  the  Subject. — It  is  quite  impossible  to  over-estimate 
the  importance  of  thoroughly  understanding  the  mechanism  of  the 
passage  of  the  foetus  through  the  pelvis.  This  dominates  the  whole 
scientific  practice  of  midwifery,  and  the  practitioner  cannot  acquire 
more  than  a  merely  empirical  knowledge,  such  as  may  be  possessed 
by  an  uneducated  midwife,  or  to  conduct  the  more  difficult  cases 
requiring  operative  interference,  with  safety  to  the  patient  or  satis- 
faction to  himself,  unless  he  thoroughly  masters  the  subject. 

In  treating  of  the  physiological  phenomena  of  labor,  it  was 
assumed  that  we  had  to  do  with  an  ordinary  case  of  head  presenta- 
tion, the  description  being  applicable,  with  slight  variations,  to  pre- 
sentations of  other  parts  of  the  foetus.  So  in  discussing  the  mechanical 
phenomena  of  delivery,  I  shall  describe  more  in  detail  the  mechanism 

'  Amer.  Med.  Journ.  1854. 


262  LABOR. 

of  head  presentations,  reserving  any  account  of  the  mechanism  of 
other  presentations  until  they  are  separately  studied.  Head  presen- 
tation is  so  much  more  frequent  than  that  of  any  other  part — 
amounting  to  95  per  cent,  of  all  cases — that  this  mode  of  studjnng 
the  subject  is  fully  justified  ;  and,  when  once  the  student  has  mastered 
the  phenomena  of  delivery  in  head  presentations,  he  will  have  little 
difficulty  in  understanding  the  mechanism  of  labor  when  other  parts 
of  the  foetus  present,  based,  as  it  always  is,  on  the  same  general  plan. 

Position  of  the  Head  hy  its  Sutures  and  Fontanelles. — In  entering  on 
this  study  we  come  to  appreciate  the  importance  of  the  sutures  and 
fontanelles  in  enabling  us  to  detect  the  position  of  the  foetal  head, 
and  to  watch  its  progress  through  its  canal:  and  unless  the  "tactus 
eruditus"  by  which  these  can  be  distinguished  from  each  other  has 
been  acquired,  the  practitioner  will  be  unable  to  satisfy  himself  of 
the  exact  progress  of  the  labor.  ISTor  is  this  always  easy.  Indeed, 
it  requires  considerable  experience  and  practice  before  it  is  possible 
to  make  out  the  position  of  the  head  with  absolute  certainty ;  but 
this  knowledge  should  always  be  aimed  at,  and  the  student  will  never 
regret  the  time  and  trouble  he  spends  in  acquiring  it. 

Position  of  the  Head  at  the  wmmenceinent  of  Luhor.- — At  the  com- 
mencement of  labor  the  long  diameter  of  the  head  lies  in  almost  any 
diameter  of  the  pelvic  brim,  except  in  the  antero-posterior,  where 
there  is  not  space  for  it.  In  the  large  majorit}'-  of  cases,  however,  it 
enters  the  pelvis  in  one  or  other  of  the  oblique  diameters,  or  in  one 
between  the  oblique  and  transverse :  but  until  it  has  fairly  passed 
through  the  brim,  it  more  frequently  lies  directly  in  the  transverse 
diameter  than  has  been  generally  supposed.  Hence  obstetricians  are 
in  the  habit  of  describing  the  head  as  lying  in  four  positions,  accord- 
ing to  the  parts  of  the  pelvis  to  which  the  occiput  points ;  the  first 
and  third  positions  being  those  in  which  the  long  diameter  of  the 
head  occupies  the  right  oblique  diameter  of  the  pelvis,  the  second 
and  fourth  those  in  which  it  lies  in  the  left  oblique.  Many  sub- 
divisions of  these  positions  have  been  made,  which  only  complicate 
the  subject,  and  render  it  more  difficult  to  understand. 

The  positions,  then,  of  the  foetal  head  after  it  has  entered  the  brim, 
which  it  is  of  importance  to  be  able  to  distinguish  in  practice  are  : — - 

First  {or  left  occipito- cotyloid). — The  occiput  points  to  the  left  fora- 
men ovale,  the  sinciput  to  the  right  sacro-iliac  synchondrosis,  and 
the  long  diameter  of  the  head  lies  in  the  right  oblique  diameter  of 
the  pelvis. 

Second  {or  right  occipito-cotyloid). — The  occiput  points  to  the  right 
foramen  ovale,  the  forehead  to  the  left  sacro-iliac  synchondrosis,  and 
the  long  diameter  of  the  head  lies  in  the  left  oblique  diameter  of  the 
pelvis. 

Third  {or  right  occijyito-sacro-iliac). — The  occiput  points  to  the  right 
sacro-iliac  synchondrosis,  the  forehead  to  the  left  foramen  ovale,  and 
the  long  diameter  of  the  head  lies  in  the  right  oblique  diameter  of 
the  pelvis.     This  position  is  the  reverse  of  the  first. 

Fourth  {or  left  occipito-sacro-iliac). — The  occiput  points  to  the  left 
sacro-iliac  synchondrosis,  the  forehead  to  the  right  foramen  ovale, 


DELIVERY    IN    HEAD    PRESENTATIONS. 


263 


and  the  long  diameter  of  the  head  lies  in  the  left  oVjlique  diameter  of 
the  pelvis.     This  position  is  the  reverse  of  the  second. 

Frequency  of  these  Positions. — The  relative  frequency  of  these 
positions  has  long  been,  and  still  is,  a  matter  of  discussion  among 
obstetricians.  According  to  Naegele,  to  whose  classical  essay  we 
owe  the  greater  part  of  our  knowledge  of  the  subject,  the  head  lies 
in  the  right  oblique  diameter  in  99  per  cent,  of  all  cases.  More  re- 
cent researches  have  thrown  some  doubt  on  the  accuracy  of  these 
figures,  and  many  modern  obstetricians  believe  that  the  second  posi- 
tion, which  ISTaegele  believed  only  to  be  observed  as  a  transitional 
stage  in  the  natural  progress  of  the  third  position,  is  much  more 
common  than  he  supposed.  This  question  will  be  more  fully  dis- 
cussed when  we  treat  of  the  mechanism  of  occipito-posterior  delivery, 
and,  in  the  meantime,  it  may  serve  to  show  the  discrepancy  which 
exists  in  the  opinions  of  modern  writers,  if  we  append  the  folloAving 
table  of  the  relative  frequency  of  the  various  positions,^  copied  from 
Leishman's  Work : — 


First 
Position. 

Second 
Position. 

Third 
Position. 

Fourth 

Position. 

Not 
Classified. 

70. 

64.64 

76.45 

70.83 

63.23 

86.36 

29. 
32.88 
22.68 
25.66 
16.18 
1.04 

1 

247 

Simpson  and  Barry  . 
Dubois     .... 

.29 

2.87 

16.18 

9.79 

.58 
.62 

4.42 

2.8 

Murpliy   .... 
Swayne    .... 

Here  it  ivill  be  seen  that  all  obstetricians  are  agreed  as  to  the  im- 
mensely greater  frequency  of  the  first  position — the  only  point  at 
issue  being  the  relative  frequency  of  the  second  and  third. 

Explanation. — Yarious  explanations  have  been  given  of  the 
greater  frequency  with  which  the  head  lies  in  the  right  oblique 
diameter.  By  some  it  is  referred  to  the  natural  tendency  of  the  back 
of  the  foetus,  as  shown  by  the  experimental  researches  of  Honing 
and  other  writers,  to  be  directed,  in  consequence  of  gravitation,  for- 
wards and  to  the  left  side  of  the  mother  in  the  erect  attitude,  and 
backwards  and  to  her  right  side  in  the  recumbent.  The  explanation 
given  by  Simpson  Avas  that  the  head  lay  in  the  right  oblique  diame- 
ter in  consequence  of  the  measurement  of  the  left  oblique  being  more 
or  less  lessened  by  the  presence  of  the  rectum.  When  the  rectum  is 
collapsed,  indeed,  the  narrowing  of  the  diameter  is  slight ;  but  it  is 
so  often  distended  by  fsecal  matter^ — -sometimes,  when  constipation 
exists,  to  a  very  great  extent— that  it  may  really  have  a  very 
important  influence  in  determining  the  position  of  the  foetal  head. 

In  describing  the  mechanism  of  delivery,  it  will  be  well  for  us  to 
concentrate  our  attention  on  the  first,  or  most  common  position, 
dwelling  subsequently  more  briefly  on  the  difi'erences  between  it  and 
the  less  common  ones. 


'  Leishman's  System  of  Midwifery,  p.  341. 


264 


LABOR. 


Description  of  the  First  Position. — In  tliis  position,  when  tlie  head 
commences  to  descend,  the  occiput  lies  in  the  brim  pointing  to  the 
left  ileo-pectineal  eminence,  the  forehead  is  directed  to  the  right 
sacro-iliac  synchondrosis,  and  the  sagittal  suture  runs  obliquely 
across  the  pelvis  in  the  right-oblique  diameter.  The  back  of  the 
child  is  turning  towards  the  left  side  of  the  mother's  abdomen,  the 
right  shoulder  to  her  right  side,  the  left  to  her  left  side  (Fig,  93),     If 


Fig.  93. 


r 

Attitude  of  Child  ia  Fii-st  Position.     (Alter  Hodi,'e.) 

a  vaginal  examination  be  now  made  (the  patient  lying  in  the  ordinary 
obstetric  position),  and  the  os  be  sufficiently  open,  the  finger  will 
impinge  upon  the  protuberance  of  the  right  parietal  bone,  which  is 
described  as  the  "  presenting  part,"  a  term  Avhich  has  received  various 
definitions,  the  best  of  which  is  probably  that  adopted  by  Tyler 
Smith,  viz.,  "that  portion  of  the  foetal  head  felt  most  prominently 
within  the  circle  of  the  os  uteri,  the  vagina,  and  the  os  tincse,  in  the 
successive  stages  of  labor."  If  the  tip  of  the  examining  finger  be 
passed  slightly  upwards,  it  will  feel  the  sagittal  suture  running 
obliquely  across  the  pelvis  and,  if  this  be  traced  downAvards  and  to 
the  left,  it  will  come  upon  the  triangular  posterior  foutanelle,  with 
the  lambdoidal  sutures  diverging  from  it.  If  the  finger  could  be 
passed  sufficiently  high  in  the  opposite  direction,  upwards  and  to  the 
right,  it  would  come  upon  the  large  anterior  fontanelle  ;  but,  at  this 
time,  that  is  too  high  up  to  be  within  reach.  The  chin  is  slightly 
ilexed  upon  the  sternum,  this  flexion,  as  we  shall  presently  see, 
being  greatly  increased  as  the  head  begins  to  descend. 

The  head,  at  the  commencement  of  labor,  generally  lies  within  the 
pelvic  brim,  especially  in  primiparse.     In  multiparee,  owing  to  the 


DELIVERY  IN  HEAD  PRESENTATIONS. 


265 


relaxation  of  the  abdominal  parietes,  the  uterus  is  apt  to  fall  some- 
what forwards,  and  the  head  eonsequently  is  more  entirely  aljove  the 
brim,  but  is  pushed  witliin  it  as  soon  as  labor  actually  commences. 

Nrxe'jle's  Views. — Naegele — and  his  description  has  been  adopted 
by  most  subsequent  writers — describes  the  head,  at  this  period,  as 
lying  obliquely  in  relation  to  the  brim,  the  right  parietal  bone,  on 
which  the  examining  finger  impinges,  being  supposed  by  him  to  be 
much  lower  than  the  left.  The  accuracy  of  this  view  has,  of  late 
years,  been  contested,  and  it  is  now  pretty  generally  admitted  that 
this  obliquity  does  not  exist,  and  that  the  head  enters  the  brim  of 
the  pelvis  with  both  parietal  bones  on  the  same  level,  and  with  its 
bi-parietal  diameter  parallel  to  the  plane  of  the  inlet  (Fig.  94).    Xae- 

FiG.  94. 


First  Position;  Movement  of  Flexion. 

gele's  view  was  adopted,  partly  because  the  finger  always  felt  the 
right  parietal  protuberance  lowest,  and  partly  because  it  was  at  that 
point  that  the  "  ca-put  succedaneum^''''  or  swelling  observed  on  the  head 
after  delivery,  was  always  formed.  Both  arguments  are,  however, 
fallacious ;  for  the  right  parietal  bone  is  the  part  which  would  natu- 
rally bs  felt  lowest,  on  account  of  the  oblique  position  of  the  pelvis 
to  the  trunk ;  while,  with  regard  to  the  caput  succedaneum,  it  has 
been  conclusively  proved  by  Duncan,  that  it  does  not  form  on  the 
point  most  exposed  to  pressure,  as  ISTaegele  assumed,  but  on  the  part 
of  the  head  where  there  is  least  pressure,  that  is  the  part  lying  over 
the  axis  of  the  vaginal  canal. 

Division  of  Mechanical  Movements  into  Stages. — In  tracing  the  pro- 
gress of  the  head  from  the  position  just  described,  obstetricians  have 
been  in  the  habit  of  dividing  the  movements  it  undergoes  into  vari- 
ous stages,  which  are  convenient  for  the  purpose  of  facilitating  de- 
scription. It  must  be  borne  in  mind  that  these  are  not  evident  and 
distinct  stages,  which  can  always  be  made  out  in  practice,  but  that 


266  LABOR. 

tliej  run  insensibly  into  one  another,  and  often  occur  simultaneously, 
or  nearly  so,  in  I'apid  labor.  They  may  be  described  as:  1.  Flexion. 
2.  First  movement  of  descent.  3.  Levelling  or  adjusting  moveme^it. 
4.  Rotation.  5.  Second  inovenieyit  of  descent  and  exieyision.  6.  Ex- 
ternal rotation. 

1.  Flexion^  the  first  movement  of  the  head  consists  of  a  rotation 
on  its  bi-parietal  diameter,  by  which  the  chin  of  the  child  becomes 
bent  on  the  sternum,  and  the  occiput  descends  lower  than  the  front 
part  of  the  head.  By  this  there  is  a  clear  gain  of  at  least  a  half  inch, 
for  the  occipito-bregmatic  diameter  (3|  inches)  becomes  substituted 
for  the  occipito-frontal  (4  inches)  (Fig.  94). 

The  movement  is  most  marked  when  the  pelvis  is  narrow,  and,  in 
some  cases  of  pelvic  deformity,  it  takes  place  to  an  extreme  degree ; 
while,  in  unusually  large  and  roomy  pelves,  it  occurs  to  a  very  slight 
extent,  or  not  at  all.  The  reason  of  this  flexion  is  twofold.  Solayres 
and  the  majority  of  obstetricians  explain  it  by  saying  that  the  ex- 
pulsive force  is  communicated  to  the  head  through  the  vertebral 
column,  and,  inasmuch  as  the  head  is  articulated  much  nearer  the 
occiput  than  the  sinciput,  the  resistance  being  equal,  the  former  must 
be  pushed  down.  This  is  doubtless  the  correct  explanation  of  the 
flexion  after  the  membranes  are  ruptured  ;  but,  before  that  happens, 
the  ovum  is  practically  a  bag  of  water,  which  is  ecpaally  compressed 
at  all  points  by  the  uterine  contractions,  and  is  pushed  downwards 
through  the  os  en  masse^  the  expulsive  force  not  being  transmitted 
through  the  vertebral  column  at  all.  Under  such  circumstances 
flexion  is  probably  effected  in  the  following  way :  the  head  being 
articulated  nearer  the  occiput  than  the  forehead,  and  being  equally 
pressed  upon  from  below  by  the  resisting  structures,  the  pressure  is 
more  effectual  on  the  forehead — consequently  that  is  forced  upwards, 
and  the  occiput  descends.  This  explanation  would  also  hold  good 
after  the  rapture  of  the  membranes,  and  probably  both  causes  assist 
in  effecting  the  movement. 

2  and  3.  Descent  and  Levelling  Movement. — The  movements  of 
descent  and  levelling  may  be  described  together.  As  soon  as  the  head 
is  liberated  from  the  os  uteri,  it  descends  pretty  rapidly  through  the 
pelvis,  until  the  occiput  reaches  a  point  nearly  opposite  the  lower 
part  of  the  foramen  ovale  (Fig.  95),  and  the  sinciput  is  opposite  the 
second  bone  of  the  sacrum.  A  levelling  movement  now  occurs,  the 
anterior  fontanelle  comes  to  be  more  easily  within  reach,  more  on  a 
level  with  the  posterior,  and  the  chin  is  no  longer  so  much  flexed  on 
the  sternum.  This  change  is  due  to  the  fact  that  the  anterior  end 
of  the  ovoid  experiences  greater  resistance  than  the  posterior,  and 
as  soon  as  this  resistance  counterbalances  and  exceeds  that  applied 
to  the  latter,  the  sinciput  must  descend.  The  right  side  of  the  head 
also  descends  more  than  the  left  from  a  similar  cause,  so  that  the 
head  becomes,  as  it  were,  slightly  flexed  on  the  right  shoulder.  This 
obliquity  of  the  head  on  its  transverse  diameter  in  the  lower  part  of 
the  pelvis  has  been  denied  by  Klineke,^  who  maintains  that  the  head 

1  Die  Vier  Factoren  cler  Geburt,  Berlin,  1869. 


DELIVERY  IN  HEAD  PRESENTATIONS. 


267 


passes  through  the  entire  pelvis  in  the  same  position  as  it  enters  the 
brim,  that  is,  with  both  parietal  bones  on  a  level,  so  that  the  point 
of  intersection  of  the  transverse  and  antero-posterior  diameters  of 
the  pelvis  would  correspond  with   the  sagittal    suture.     There   is, 


Fig.  95. 


First  Positioa  ;  Occiput  ia  the  Cavity  of  the  Pelvis.     (After  Hodgo.) 


however,  good  reason  to  believe  that,  in  the  lower  half  of  the  pelvic 
cavity,  the  head  is  not  truly  sjnclitic,  as  Kuneke  describes,  but  that 
the  right  parietal  bone  is  on  a  somewhat  lower  level  than  the  left. 

4.  Rotation. — -The  movement  of  rotation  is  very  important.  By  it 
the  long  diameter  of  the  head  is  changed  from  the  oblique  diameter 
of  the  pelvic  cavity  to  the  antero-posterior  diameter  of  the  outlet 
(Fig.  96),  or  to  a  diameter  nearly  corresponding  to  it,  so  that  the 

Fig.  96. 


First  Position  :  Occiput  at  outlet  of  Pelvis.     (After  Hodge.) 

long  diameter  of  the  head  is  brought  into  relation  with  the  longest 
diameter  of  the  pelvic  outlet.  This  alteration  almost  always  takes 
place,  and  may  be  readily  observed  by  the  accoucheur  who  carefully 
watches  the  progress  of  labor.  Various  explanations  have  been 
given  of  its  causes.  The  one  most  generally  adopted  is,  that  it  is 
due  to  the  projection  inwards  of  the  ischial  spines,  which  narrow  the 
transverse  diameter  of  the  pelvic  outlet.  As  the  pains  force  the 
occiput  downwards,  its  rotation  backwards  is  prevented  by  the  pro- 
jection of  the  left  ischial  spine,  while  its  rotation  forwards  is  favored 
by  the  smooth  bevelled  surface  of  the  ascending  ramus  of  the 
ischium.  Similarly  the  ischial  spine  on  the  opposite  side  prevents 
the  rotation  forwards  of  the  forehead,  which  is  guided  backwards  to 
the  cavity  of  the  sacrum  by  the  smooth  surface  of  the  sacro-ischi- 


268  LABOR. 

atic  ligaments.  These  arrangements,  therefore,  give  a  screwlike 
form  to  the  interior  of  the  pelvis ;  and  as  the  pains  force  the  head 
downwards,  tliej  are  effectual  in  imparting  to  it  the  rotatory  move- 
ment which  is  of  such  importance  in  adapting  it  to  the  longest 
measurement  of  the  outlet. 

By  most  of  the  German  obstetricians  the  influence  of  the  ischial 
spines,  and  of  the  smooth  pelvic  planes  in  producing  rotation  is  not 
admitted.  They  rather  refer  the  change  of  direction  to  the  in- 
creased resistance  the  head  meets  from  the  posterior  wall  of  the 
pelvis,  and  from  the  perineal  structures.  Whichever  part  of  the 
head  first  meets  this  resistance,  which  is  much  greater  than  that  of 
the  anterior  part  of  the  pelvis,  must  necessarily  be  pressed  forwards  ; 
and  as,  in  the  large  majority  of  cases,  the  posterior  fontanelle  de- 
scends first,  it  is  thus  pressed  forwards  until  rotation  is  effected. 
This  view  has  the  advantage  of  accounting  equally  well  for  the  rota- 
tion in  occipito-posterior  as  in  occipito-anterior  positions,  the  former 
of  which,  on  the  more  ordinarily  received  theory,  are  not  quite  satis- 
factorily explicable.  It  does  not  follow  that  the  smooth  surfaces  of 
the  pelvic  planes  are  without  influence  in  favoring  the  rotation.  On 
the  contrary,  they  probably  greatly  facilitate  it ;  but  it  is  more  sim- 
ply and  effectually  explained  by  the  latter  theory  than  by  that 
which  attributes  so  important  an  action  to  the  ischial  spines. 

In  some  rare  cases  the  head  escayjes  rotation  and  reaches  the  per- 
ineum still  lying  in  the  oblique  diameter.  Even  here,  however, 
rotation  is  generally  effected,  often  suddenly,  just  as  the  head  is  about 
to  pass  the  vulva,  and  it  is  very  rarely  expelled  in  the  oblique  posi- 
tion. The  movement  at  this  stage  may  be  explained  by  the  peri- 
neum, which  is  attached  at  its  sides,  and  grooved  in  its  centre :  to  the 
hollow  so  formed  the  long  diameter  of  the  head  accommodates  itself, 
and  is  thus  rotated  into  the  an tero- posterior  diameter  of  the  outlet. 

5.  Extension — By  the  process  just  described  the  face  is  turned 
back  into  the  hollow  of  the  sacrum ;  but  the  head  does  not  lie  abso- 
lutely in  the  antero-posterior  diameter  of  the  pelvic  outlet,  but 
rather  in  one  between  it  and  the  oblique.  The  occiput  is  still  forced 
down  by  the  pains,  and,  in  consequence  of  its  altered  position,  is  en- 
abled to  pass  between  the  rami  of  the  pubis,  and  advances  until  its 
further  descent  is  checked  by  the  nape  of  the  neck,  which  is  pressed 
under  and  against  the  arch  of  the  pubes.  By  this  means  the  occiput 
is  fixed,  and  the  pains  continuing,  the  uterine  force  no  longer  acts 
on  the  occiput,  but  on  the  anterior  part  of  the  head,  which  is  now 
pushed  down  and  separated  from  the  sternum.  This  constitutes 
extension.  As  the  head  descends,  the  soft  structures  of  the  perineum 
are  stretched,  and  the  coccyx  pushed  back  so  as  to  enlarge  the  out- 
let. The  pains  continue  to  distend  the  perineum  more  and  more, 
the  head  advancing  and  receding  with  each  pain.  As  the  forehead 
descends,  the  sub-occipito-bregmatic,  the  sub-occipito-frontal,  and  the 
sub-occipito-mental  diameters  successively  present ;  the  occiput  turns 
more  and  more  upwards  in  front  of  the  pubes  (Fig.  97),  and,  at  last, 
the  face  sweeps  over  the  perineum  and  is  born. 

The  mechanical  cause  of  this  movement  may  be  readily  explained. 


DELIVERY  IN  HEAD  PRESENTATIONS. 


269 


As  soon  as  the  occiput  has  passed  under  the  arch  of  the  pubis,  and 
is  no  longer  resisted  by  the  anterior  pelvic  walls,  the  head  is  sub- 
jected to  the  action  of  two  forces:  that  of  the  uterine  pressure  act- 
ing downwards  and  backwards ;   and  that  of  the  resistance  of  the 


Fig.  97. 


First  position :  Head  delivered.     (After  Hodge.) 

posterior  walls  of  the  pelvis  and  the  soft  parts,  acting  almost  directly 
forwards.  The  necessary  result  is  that  the  head  is  pushed  in  a  direc- 
tion intermediate  between  these  two  opposing  forces — that  is,  down- 
wards and  forwards  in  the  axis  of  the  pelvic  outlet. 

In  addition  to  the  slight  obliquity  which  exists  as  regards  the 
direct  relation  of  the  long  diameter  of  the  head  to  the  antero-poste- 
rior  diameter  of  the  outlet  at  the  mojiient  of  its  expulsion,  the  head 
also  lies  somewhat  obliquely  in  relation  to  its  own  transverse  diame- 
ter, so  that,  in  the  majority  of  cases,  the  right  parietal  bone  is  ex- 
pelled before  the  left. 

6.  External  Rotation. — Shortly  after  the  head  is  expelled,  as  soon 
as  renewed  uterine  action  commences,  it  may  be  observed  to  make  a 

Fig.  98. 


External  Rotation  of  Head  in  First  Position.     (After  Hodge.) 

distinct  rotatory  movement,  the  occiput  turning  to  the  left  thigh  of 
the  mother,  and  the  face  turning  upward  to  the  right  thigh  (Fig.  98). 
The  reason  of  this  is  evident.     When  the  head  descends  in  the  right 


270 


LABOR. 


oblique  diameter  the  shoulders  lie  in  the  opposite  or  left  oblique  diam- 
eter, and  as  the  head  rotates  into  the  antero-posterior  diameter,  they 
are  necessarily  placed  more  nearly  in  the  transverse.  As  soon  as  the 
head  is  expelled  the  shoulders  are  subjected  to  the  same  uterine  force 
and  pelvic  resistance  as  the  head  has  just  been,  and  they  are  acted 
on  in  precisely  the  same  way.  Consequently  they  too  rotate,  but  in 
the  opposite  direction,  into  the  antero-posterior  diameter  of  the  out- 
let, or  nearly  so,  just  as  the  head  did,  and  as  they  do  so,  they  neces- 
sarily carry  the  head  with  them,  and  cause  its  external  rotation. 

The  two  shoulders  are  soon  expelled,  the  left  shoulder  generally 
the  first,  sweeping  over  the  perineum  in  The  same  manner  as  the  face. 
This  is,  however,  not  always  the  case,  and  they  are  often  expelled 
simultaneously,  or  the  right  shoulder  may  come  first.  The  body 
soon  follows,  and  the  second  stage  of  labor  is  completed. 

Second  Position. — In  the  second  position  (right  occipito-cotyloid) 
the  long  diameter  of  the  head  lies  in  the  left  oblique  diameter  of  the 
pelvis.  On  making  a  vaginal  examination,  in  the  ordinary  obstetric 
position,  the  finger,  passing  upwards  and  to  the  right,  feels  the  small 
posterior  fontanelle  ;  downwards  and  to  the  left,  it  feels  the  anterior. 
The  sagittal  suture  lies  obliquely  across  the  pelvis  in  the  left  oblique 
diameter.  The  description  of  the  mechanism  of  delivery  is  precisely 
the  same  as  in  the  first  position,  substituting  the  word  left  lor  right. 
Thus  the  finger  impinges  on  the  left  parietal  bone,  the  occiput  turns 
from  right  to  left  daring  rotation.  After  the  birth  of  the  head  the 
occiput  turns  to  the  right  thigh  of  the  mother,  the  face  to  the  left 
thigh. 

Third^  or  Right  Occi/pito-sacro-iliac  Position. — In  the  lhird  position 
the  head  enters  the  pelvic  brim  with  the  occiput  directed  backwards 


Fig.  99. 


Third  Position  of  Occiput,  at  Brim  of  Pelvis. 


to  the  right  sacro-iliac  svnchondrosis,  and  the  sinciput  forwards  to 
the  left  foramen  ovale  (Pig.  99).     The  posterior  fontanelle  is  directed 


DELIVERY    IN    HEAD    PRESENTATIONS.  271 

backwards,  the  anterior  fontanclle  forwards,  while  the  examining 
finger  impinges  on  the  left  parietal  bone.  The  mechanism  of  de- 
livery in  these  cases  is  of  much  interest.  In  tlie  large  majority  of 
cases,  during  the  progress  of  delivery,  the  occijjut  rotates  forwards 
along  the  right  side  of  the  pelvis,  until  it  comes  to  lie  almost  in  the 
antero-posterior  diameter  of  the  outlet,  and  passes  under  the  pubic 
arch,  the  forehead  passing  over  the  perineum.  It  will  be  seen  that 
during  part  of  this  extensive  rotation  the  head  must  lie  in  the  second 
position,  and  the  case  terminates  just  aa  if  it  had  been  in  the  second 
position  from  the  commencement  of  labor. 

Manner  in  which  the  Occiput  is  Rotated  Forwards. — How  is  it  that 
this  rotation  is  effected,  and  that  the  sinciput,  occupying  the  posi- 
tion of  the  occiput  in  the  first  position,  should  not  be  rotated  for- 
wards to  the  ])ubes  as  that  is?  This,  no  doubt,  may  be  explained 
by  the  fact,  that  the  uterine  force  transmitted  through  the  vertebral 
column  causes  the  occiput  to  descend  lower  than  the  sinciput,  so  that 
in  most  cases,  in  making  a  vaginal  examination,  the  posterior  fonta- 
nclle can  be  readily  felt,  while  the  anterior  is  high  up  and  out  of 
reach.  The  head  is,  therefore,  extremely  flexed,  and  so  descends  into 
the  pelvic  cavity,  until  the  occiput,  being  now  below  the  right  ischial 
spine,  experiences  the  resistance  of  the  pelvic  floor,  opposite  the 
right  sacro-ischiatic  ligament,  by  which  it  is  directed  forwards.  The 
forehead  is,  at  this  time,  supposing  flexion  to  be  marked,  too  high 
to  be  influenced  by  the  anterior  pelvic  plane.  Pressure  continuing, 
the  occiput  rotates  forwards,  the  forehead  passes  round  the  left  side 
of  the  pelvis,  and  labor  is  terminated  as  in  the  second  position. 

The  period  of  labor  at  which  rotation  takes  place  varies.  In  the 
majority  of  cases  it  does  not  occur  until  the  head  is  on  the  floor  of 
the  pelvis,  for  it  is  then  that  resistance  is  most  felt ;  but  the  greater 
the  resistance,  the  sooner  will  rotation  be  produced.  Hence  it  is 
more  likely  to  occur  early  when  the  head  is  large,  and  the  pelvis 
comparatively  small. 

The  facility  with  which  this  movement  is  effected  obviously  de- 
pends upon  the  complete  flexion  of  the  chin  on  the  sternum,  by  which 
the  anterior  fontanelle  is  so  elevated  that  its  rotation  backwards  is 
not  resisted  by  the  inward  projection  of  the  left  ischial  spine,  and 
the  occiput  is  correspondingly  depressed.  If,  however,  this  flexion 
is  not  complete,  and  the  anterior  fontanelle  is  so  low  as  to  be  readily 
within  reach  of  the  finger,  considerable  difficulty  is  likely  to  be  ex- 
perienced. In  many  such  cases  rotation  is  still  eventually  effected, 
but  in  others  it  is  not ;  and  the  labor  is  then  terminated  with  the 
face  to  the  pubes,  but  at  the  expense  of  considerable  delay  and  diffi- 
culty. According  to  Dr.  Uvedale  West,  of  Alford,  who  devoted  much 
careful  study  to  the  subject,  this  termination  occurs  in  about  4  per 
cent,  of  occipito-posterior  positions.  AVhen  it  is  about  to  happen  the 
anterior  fontanelle  may  be  felt  very  low  down,  and,  sometimes,  even 
the  forehead  and  superciliary  ridges.  The  uterine  force  pushes  down 
the  occiput,  the  sinciput  being  fixed  behind  the  pubes,  which  it  ob- 
viously cannot  pass  under,  as  does  the  occiput  in  the  first  position. 
The  sinciput,  therefore,  becomes  more  flexed  and   pushed  upwards, 


272  LABOR. 

while  tlie  resistance  of  the  pelvic  floor  directs  the  occiput  forwards. 
The  perineum  now  becomes  enormously  distended  by  the  back  part 
of  the  head,  and  is  in  great  danger  of  laceration.  The  occiput  is  even- 
tually, but  not  without  much  difficulty,  expelled.  A  process  of  ex- 
tension now  occurs,  the  nape  of  the  neck  being  fixed,  as  it  were, 
against  the  centre  of  the  perineum,  the  expelling  force  now  acting  on 
the  forehead,  and  producing  rotation  of  the  head  on  its  transverse 
axis.  The  forehead  and  face  are  thus  protruded,  and  the  body  fol- 
lows without  difficulty. 

It  is  said  that,  in  a  few  exceptional  cases,  where  the  anterior  fon- 
tanelle  is  much  depressed,  the  labor  may  terminate  by  the  conversion 
of  the  presentation  into  one  of  the  face,  the  head  rotating  on  its  trans- 
verse axis,  the  forehead  passing  to  the  posterior  part  of  the  pelvis, 
and  the  chin  emerging  under  the  perineum.  It  is  obvious,  however, 
that  this  change  can  only  occur  when  the  head  is  unusually  small, 
and  it  must  of  necessity  be  extremely  rare. 

.Relative  frequency  of  Second  and  Third  Positions. — Reference  has 
already  been  made  to  Naegele's  views  as  to  the  rarity  of  the  second 
position,  and  to  his  opinion  that  cases  in  which  the  occiput  was  found 
to  point  to  the  right  foramen  ovale  were  only  transitional  stages  in 
the  rotation  of  occipito-posterior  positions.  Such  an  assumption, 
however,  is  unwarrantable,  unless  the  case  has  been  watched  from 
the  very  commencement  of  labor.  Many  perfectly  qualified  ob- 
servers have  arrived  at  the  conclusion  that  second  positions  are  far 
more  common  than  Naegele  supposed ;  and  in  the  table  already 
quoted  it  will  be  seen  that  while  Murphy  estimates  the  second  and 
third  as  being  equally  frequent,  Swayne  believes  the  second  to  be 
much  more  common  than  the  third.  It  is  probable  that  the  weight 
of  JSTaegele's  authority  has  induced  many  observers  to  classify  second 
positions  as  third  positions  in  which  partial  rotation  has  already 
been  accomplished.  My  own  experience  would  certainly  lead  me  to 
think  that  second  positions  are  very  far  from  uncommon.  The  ques- 
tion, however,  must  be  considered  to  be  in  abeyance,  until  further 
observations  by  competent  authorities  enable  us  to  decide  it  conclu- 
sively. 

Fourth  or  Left  Occipito-sacro-ischiatic. — The  fourth  position  is  just 
as  much  the  reverse  of  the  second  as  the  third  is  of  the  first.  The 
occiput  points  to  the  left  (Fig.  100)  sacro-iliac  synchondrosis,  and  the 
finger  impinges  on  the  right  parietal  bone.  The  mechanism  is  pre- 
cisely the  same  as  in  the  third  position,  the  rotation  taking  place 
from  left  to  right. 

Formation  of  the  Caput  Succedaneum. — The  formation  of  the  caput 
succedaneum  has  been  already  alluded  to.  This  term  is  applied  to 
the  oedematous  swelling  which  forms  on  the  head,  and  is  produced 
by  effusion  from  the  obstruction  of  the  venous  circulation  caused  by 
the  pressure  to  which  the  head  is  subjected.  It  follows  that  the  size 
of  the  swelling  is  in  direct  proportion  to  the  length  of  the  labor.  In 
rapid  deliveries,  in  which  the  head  is  forced  through  the  pelvis 
quickly,  it  is  scarcely,  if  at  all,  developed ;  while  after  protracted 
labors,  it  is  large  and  distinct,  and  may  obscure  the  diagnosis  of  the 


DELIVERY    IN    HEAD    PRESENTATIONS. 


273 


position,  l)v  preventing  the  sutures  and  fontanelles  being  felt.  Its 
situation  varies  according  to  the  position  of  the  head :  thus,  in  the 
first  and  fourth  positions  it  forms  on  the  right  parietal  bone,  in.  the 
second  and  third  on  the  left ;  and  wc  may,  therefore,  verify,  by  in- 
spection of  its  site,  the  accuracy  of  our  diagnosis. 


Fig.  100. 


Fourth  Position  of  Occiput  at  Pelvic  Brim. 

An  ordinary  mistake  which  has  been  made  by  obstetricians  is  to 
regard  the  caput  succedaneum  as  formed  at  the  point  where  the 
head  has  been  most  subjected  to  pressure ;  while,  in  fact,  it  forms  on 
that  part  which  is  most  unsupported  by  the  maternal  structures,  and 
where  the  swelling  may  consequently  most  readily  occur.  There- 
fore, in  the  early  stages  of  the  labor,  it  always  forms  on  the  part  of 
the  head  which  lies  in  the  circle  of  the  os  uteri ;  while,  in  subsequent 
stages,  it  forms  on  that  which  lies  in  the  axis  of  the  vaginal  canal, 
and  eventually  is  most  prominent  on  the  part  that  is  first  expelled 
from  the  vulva. 

Alteration  in  the  Shape  of  the  Head  from  Moulding.- — A  few  words 
may  be  said  as  to  the  alteration  in  the  form  of  the  foetal  head  which 
occurs  in  tedious  labors,  and  results  from  the  moulding  which  it  has 
undergone  in  its  passage  through  the  pelvis.  The  smaller  the  pelvis, 
and  the  greater  the  pressure  applied  to  the  head  during  delivery,  the 
more  marked  this  is.  The  result  is,  that  in  vertex  presentations  the 
occipito- mental  and  occipito-frontal  diameters  are  elongated  to  the 
extent  of  an  inch,  or  even  more,  while  the  transverse  diameters  are 
lessened,  from  compression  of  the  parietal  bones.  This  moulding  is 
of  unquestionable  value  in  facilitating  the  birth  of  the  child.  The 
amount  of  apparent  deformity  is  very  considerable,  and  may  even 
give  rise  to  some  anxiety.  It  is  well  to  remember,  therefore,  that  it 
is  always  transient,  and  that  in  a  few  hours,  or  days  at  most,  the 
elasticity  of  the  soft  cranial  bones  causes  them  to  resume  their  natural 
form.  The  caput  succedaneum  also  disappears  rapidly,  therefore  no 
amount  of  deformity  from  either  of  these  causes  need  give  rise  to 
anxiety,  or  call  for  any  treatment. 


274  LABOR. 


CPIAPTEK  III. 

MANAGEMENT  OF  NATUKAL  LABOR. 

Although  labor  is  a  strictly  physiological  function,  and  in  a  large 
majority  of  cases,  might,  no  clonbt,  be  safely  accomplished  without 
assistance  from  the  accoucheur,  still  medical  aid.  properly  given,  is 
always  of  value  in  facilitating  the  process,  and  is  often  absolutely 
essential  for  the  safety  of  the  mother  and  child. 

Preparatory  Treatment. — The  management  of  the  pregnant  woman 
before  delivery  is  a  point  which  should  always  receive  the  attention 
of  the  medical  attendant,  since  it  is  of  consequence  that  the  labor 
should  come  on  when  she  is  in  as  good  a  state  of  health  as  possible. 
For  this  purpose  ordinary  hygienic  precautions  should  never  be 
neglected  in  the  latter  months  of  gestation.  The  patient  should  take 
regular  and  gentle  exercise,  short  of  fatigue,  and,  if  the  weather 
permit,  should  spend  as  much  of  her  time  as  possible  in  the  open  air, 
Hot  rooms,  late  hours,  and  excitement  of  all  kinds  should  be  strictly 
avoided.  The  diet  should  be  simple,  nutritious,  and  unstimulating. 
The  state  of  the  bowels  should  be  particularly  attended  to.  During 
the  few  days  preceding  labor  the  descent  of  the  uterus  often  causes 
pressure  on  the  rectum,  and  prevents  its  evacuation.  Hence  it  is 
customary  to  prescribe  occasional  gentle  aperients,  such  as  small 
doses  of  castor  oil,  for  a  few  days  before  the  expected  period  of  de- 
livery. Some  caution,  however,  is  necessary,  as  it  is  certainly  not 
very  uncommon  for  labor  to  be  determined  rather  sooner  than  was 
anticipated,  in  consequence  of  the  irritation  of  too  large  a  purgative 
dose.  The  state  of  the  bowels  should  always  be  inquired  into  at  the 
commencement  of  labor,  and,  if  there  be  any  reason  to  suspect  that 
they  are  loaded,  a  copious  enema  should  be  administered.  This  is 
always  a  proper  precaution  to  take,  for  a  loaded  rectum  is  a  common 
cause  of  irregular  and  ineffective  uterine  action ;  and  even  when  it 
does  not  produce  this  result,  the  escape  of  the  feces,  in  consequence 
of  pressure  on  the  bowel  during  the  propulsive  stage,  is  always  dis- 
agreeable both  to  the  patient  and  practitioner. 

Dress  of  Patient  during  Pregnancy. — ^^The  dress  of  the  patient  dur- 
ing pregnancy  may  be  here  adverted  to ;  for  much  discomfort  may 
arise,  and  the  satisfactory  progress  of  labor  may  even  be  interfered 
with,  from  errors  in  this  respect. 

After  the  uterus  has  risen  out  of  the  pelvis  the  ordinary  corset, 
which  most  women  wear,  is  apt  to  produce  very  injurious  pressure ; 
still  more  so  when  attempts  are  made  to  conceal  the  increased  size 
by  tight  lacing.  After  the  fourth  or  fifth  month,  therefore,  the 
comfort  of  the  patient  is  much  increased  by  wearing  a  specially  con- 


MANAGEMENT  OF  NATURAL  LABOR.  275 

structcd  pair  of  stays,  Avitli  elastic  let  into  the  sides  and  front,  so  that 
they  accommodate  tliemselves  to  the  gradual  increase  of  the  iigure. 
Such  are  made  by  all  stay- makers,  and  should  be  worn  whenever 
the  circumstances  of  the  patient  permit.  Failing  this  it  is  better  to 
avoid  the  use  of  the  corset  altogether,  and  to  have  as  little  pressure 
on  the  uterus  as  possible ;  although  many  women  cannot  do  without 
the  support  to  which  they  are  accustomed.  To  multipara3,  especially 
if  there  bo  much  laxity  of  the  abdominal  parietes,  a  well-iittiug  elas- 
tic abdominal  belt  is  often  a  great  comfort.  This  is  constructed  so 
that  it  can  be  tightened  when  the  j^atient  is  walking  and  in  the  erect 
position,  when  such  support  is  most  required,  and  readily  loosened 
when  desired. 

Necessity  of  Attendiny  to  the  First  Summons. — It  is  hardly  neces- 
sary to  insist  on  the  necessity  of  the  practitioner  attending  imme- 
diately to  the  first  summons  to  the  patient.  It  is  true  that  he  may 
very  often  be  sent  for  long  before  lie  is  actually  required.  But  on 
the  other  hand,  it  is  quite  impossible  to  foresee  what  may  be  the 
state  of  any  individual  case.  By  prompt  attention  he  may  be  able 
to  rectify  a  malposition,  or  prevent  some  impending  catastrophe,  and 
thus  save  his  patient  from  consequences  of  the  utmost  gravity. 

Articles  to  be  taken  hy  the  Accoucheur. — The  practitioner  should 
always  be  provided  with,  the  articles  which  he  may  require.  The 
ordinary  obstetric  cases,  containing  one  or  two  bottles  and  a  catheter, 
such  as  are  sold  by  most  instrument-makers,  are  cumbrous  and  use- 
less: while  "obstetric  bags"  are  expensive  luxuries  not  within  the 
reach  of  all.  Every  one  can  manufacture  an  excellent  obstetric  bag 
for  himself,  at  a  small  expense,  by  having  compartments  for  holding 
bottles  stitched  on  to  the  sides  of  an  ordinary  leather  bag,  such  as  is 
sold  for  a  few  shillings  at  any  portmanteau- maker's.  It  is  a  great 
comfort  to  have  at  hand  all  that  may  be  required,  and  the  bag  should 
contain  chloroform  or  other  an£esthetic,  chloral,  laudanum,  the  liquor 
ferri  perchloridi  of  the  Pharmacopoeia,  the  liquid  extract  of  ergot, 
and  a  hypodermic  syringe,  with  a  bottle  containing  a  solution  of 
ergotine  for  subcutaneous  injection.  If  it  also  contain  a  Higginson's 
syrine,  a  small  elastic  catheter,  a  good  pair  of  forceps,  and  one  or 
two  suture  needles,  with  some  silver  wire  or  carbolized  catgut,  the 
practitioner  is  provided  against  any  ordinary  contingency.  Other 
articles  that  may  be  required,  such  as  thread,  scissors,  and  the  like, 
are  generally  provided  by  the  nurse  or  patient. 

Duties  071  first  Visiting  the  Patient. — On  arriving  at  the  house  the 
practitioner  should  have  his  visit  announced  to  the  patient,  and  he 
will  very  often  find  that  the  first  effect  of  his  presence  is  to  arrest 
the  pains  that  have  been  hitherto  progressing  rapidly;  thereby  af- 
fording a  very  conclusive  proof  of  the  influence  of  mental  impres- 
sions on  the  progress  of  labor.  If  the  pains  be  not  already  propulsive, 
it  is  well  that  he  should  occupy  himself  at  first  in  general  inquiries 
from  the  attendants  as  to  the  progress  of  the  labor,  and  in  seeing 
that  all  the  necessary  arrangements  are  satisfactorily  carried  out,  so 
as  to  allow  the  patient  time  to  get  accustomed  to  his  presence.  If 
he  have  any  choice  in  the  matter,  he  should  endeavor  to  secure  a 


276  LABOR. 

large,  airy,  and  well-ventilated  apartment  for  tlie  lying-in  room,  as 
far  removed  as  possible  from  witliout.  He  may  also  see  to  the  bed, 
which  should  be  without  curtains,  and  prepared  for  the  labor  by 
having  a  water-proof  sheeting  laid  under  a  folded  blanket  or  sheet, 
on  which  the  patient  lies.  These  receive  the  discharges  during 
labor,  and  can  be  pulled  from  under  the  patient  after  delivery,  so  as 
to  leave  the  dry  clothes  beneath.  Among  the  lower  classes,  the 
lying-in  chamber  is  considered  a  legitimate  meeting-place  for  nu- 
merous female  friends  to  gossip,  whose  conversation  is  often  distress- 
ing, and  is  certainly  injurious,  to  a  woman  in  the  excitable  condition 
associated  with  labor.  The  medical  attendant  should,  therefore,  insist 
on  as  much  quiet  as  possible,  and  should  allow  no  one  in  the  room 
except  the  nurse  and  some  one  friend  whose  presence  the  patient 
may  desire.  The  husband's  presence  must  be  left  to  the  wishes  of 
the  patient.  Some  women  like  their  husbands  to  be  with  them,  while 
others  prefer  to  be  without  them,  and  the  medical  attendant  is  bound 
to  act  in  accordance  with  the  patient's  desire. 

Vag'hial  Examinatio7i. — If  pains  be  actually  present  a  vaginal  ex- 
amination is  essential,  and  should  not  be  delayed.  It  enables  us  to 
ascertain  whether  the  labor  has  commenced  or  not,  and  whether  the 
presentation  is  natural  or  otherwise.  The  pains,  although  apparently 
severe,  may  be  altogether  spurious,  and  labor  may  not  have  actually 
commenced.  It  is  of  much  importance,  both  for  our  own  credit  and 
comfort,  that  we  should  be  able  to  diagnose  the  true  character  of  the 
pains;  for  if  they  be  so-called  "false"  pains,  we  might  wait  hours 
in  fruitless  expectation  of  progress,  while  delivery  is  still  far  off. 
The  necessity  of  ascertaining,  therefore,  the  actual  state  of  affairs  need 
not  further  be  insisted  on. 

Character  of  False  Pains. — False  pains  are  chiefly  characterized  by 
their  irregularity,  sometimes  coming  on  at  short  intervals,  sometimes 
with  many  hours  between  them ;  they  also  vary  much  in  intensity, 
some  being  very  sharp  and  painful,  while  others  are  slight  and  tran- 
sient. In  these  respects  they  differ  from  the  true  pains  of  the  first 
stage,  which  are  at  first  slight  and  short,  and  gradually  recur  with 
increased  force  and  regularity.  The  situation  of  the  two  kinds  of  pains 
also  varies,  the  false  pains  being  chiefly  situated  in  front,  while  the 
true  pains  are  felt  most  in  the  back,  and  gradually  shoot  round  to- 
wards the  abdomen.  Nothing  short  of  a  vaginal  examination  will 
enable  us  to  clear  up  the  diagnosis  satisfactorily.  If  the  labor  have 
actually  commenced,  the  os  will  be  more  or  less  dilated,  and  its  edges 
thinned;  while  with  each  pain  the  cervix  will  become  rigid,  and  the 
membranes  tense  and  prominent.  The  false  pains,  on  the  contrary, 
have  no  effect  on  the  cervix,  which  remains  flaccid  and  undilated ; 
or,  if  the  os  be  sufficiently  open  to  admit  the  tip  of  the  finger,  the 
membranes  will  not  become  prominent  during  the  contraction.  Un- 
der such  circumstances  we  may  confidently  assure  the  patient  that 
the  pains  are  false,  and  measures  should  be  taken  to  remove  the  irri- 
tation which  produces  them.  In  the  large  majority  of  cases  the  cause 
of  the  spurious  pains  will  be  found  to  be  some  disordered  state  of 
the  intestinal  tract ;  and  they  will  be  best  remedied  by  a  gentle  ape- 


MANAGEMENT  OF  NATURAL  LABOR.  277 

rient — such  as  castor  oil,  or  the  compound  colocyuth  pill  with  hyos- 
cjarnus — followed  by,  or  combined  with,  a  sedative,  such  as  twenty 
minims  of  laudanum  or  chlorodyne.  Shortly  after  this  has  been 
administered  the  false  pains  will  die  away,  and  not  recur  until  true 
labor  commences. 

Mode  of  conducting  a  Vayiiial  Exarainaiion. — For  a  vaginal  exami- 
nation the  patient  is  placed  by  the  nurse  on  her  left  side,  close  to  the 
edge  of  the  bed,  with  the  legs  flexed  on  the  abdomen.  The  prac- 
titioner being  seated  by  the  edge  of  the  bed,  passes  the  index  finger 
of  the  right  hand,  previously  lubricated  with  lard  or  cold  cream,  up 
to  the  vulva,  and  gently  insinuates  it  into  the  orifice  of  the  vagina, 
then  pushes  it  backwards  in  the  axis  of  the  vaginal  outlet,  and 
finally  turns  it  upwards  and  forwards  so  as  to  more  readily  reach  the 
cervix.  This  it  may  not  always  be  easy  to  do,  for  at  the  commence- 
ment of  labor  the  cervix  may  be  so  high  as  to  be  reached  with  dif- 
ficulty, or  it  may  be  directed  backwards  so  as  to  point  towards  the 
cavity  of  the  sacrum.  The  exploration  is  often  much  facilitated  by 
depressing  the  uterus  from  without,  by  the  left  hand  placed  on  the 
abdomen.  Our  object  is  not  only  to  ascertain  the  state  of  the  cervix 
as  to  softness  and  dilatation,  but  also  the  presentation,  the  condition 
of  the  vagina,  and  the  capacity  of  the  pelvis.  The  examination  is 
generally  commenced  duiing  a  pain,  at  which  time  it  is  less  distress- 
ing to  the  patient ;  but  in  order  to  be  satisfactory,  the  finger  must 
remain  in  the  vagina  until  the  pain  is  over,  the  examination  being 
concluded  in  the  interval  between  this  pain  and  the  next. 

In  head  presentations  the  round  mass  of  the  cranium  is  generally 
at  once  felt  through  the  lower  part  of  the  uterus,  and  then  we  have 
the  satisfaction  of  being  able  to  assure  the  patient  that  all  is  right. 
If  the  OS  be  sufnciently  dilated,  we  can  also  feel  through  it  the  occi- 
put covered  by  the  membranes.  It  is  impossible  at  this  time  to 
make  out  the  exact  position  of  the  head  by  means  of  the  sutures  and 
fontanelles,  which  are  too  high  up  to  be  within  reach.  Nor  should 
any  attempt  be  made  to  do  so,  for  fear  of  prematurely  rupturing  the 
membranes.  The  fact  that  the  head  is  presenting  is  all  that  we 
require  to  know  at  this  stage  of  the  labor. 

The  Condition  of  the  Os  as  indicating  the  Progress  of  Labor, — The 
condition  of  the  os  itself,  as  to  rigidity  and  dilatation  will  materially 
assist  us  in  forming  an  opinion  as  to  the  progress  and  probable  dura- 
tion of  the  labor;  but,  although  the  friends'will  certainly  press  for 
an  opinion  on  this  point,  the  cautious  practitioner  will  be  careful  not 
to  commit  himself  to  a  positive  statement,  which  may  so  easily  be 
falsified.  It  will  suffice  to  assure  the  friends  that  everything  is  satis- 
factory, but  that  it  is  impossible  to  say  with  any  certainty  how 
rapidly,  or  the  reverse,  the  case  may  progress. 

If  the  pains  be  not  very  frequent  or  strong,  and  the  os  not  dilated 
to  more  than  the  size  of  a  shilling,  a  considerable  delay  may  be  antici- 
pated, and  the  presence  of  the  medical  attendant  is  useless.  He 
may,  therefore,  safely  leave  the  patient  for  an  hour  or  more,  provided 
he  be  within  easy  reach.  It  is  needless  to  say  that  this  should  never 
be  done  unless  the  exaet  presentation  be  made  out.     If  some  part, 


278 


LABOR. 


other  than  the  head,  be  presenting,  it  will  probably  be  impossible  to 
make  it  oat  until  dilatation  has  progressed  farther ;  and  the  prac- 
titioner mast  be  incessantly  on  the  watch  until  the  nature  of  the  case 
be  made  out,  so  as  to  be  able  to  seize  the  most  favorable  moment  for 
interference,  shoald  that  be  necessary. 

Position  of  Patient  during  First  Stage. — The  position  of  the  patient 
is  a  matter  of  some  moment  in  the  first  stage.  It  is  a  decided  ad- 
vantage that  she  should  not  be  then  in  a  recumbent  position  on  her 
side,  as  is  usual  in  the  second  stage;  for  it  is  of  importance  that  the 
expulsive  force  should  act  in  such  a  way  as  to  favor  the  descent  of 
the  head  into  the  pelvis,  i.  e.,  perpendicularly  to  the  plane  of  its  brim, 
and  also  that  the  weight  of  the  child  should  operate  in  the  same  Avay. 
Therefore,  the    ordinary    custom  of  allowing   the  patient  to    walk 


Fig.  101. 


Examination  durinsr  the  first  stage. 


about,  or  to  recline  in  a  chair,  is  decidedly  advantageous;  and  it  will 
often  be  observed  that  the  pains  are  more  lingering  and  ineffective  if 
she  lie  in  bed.  If  the  patient  be  a  multipara,  or  if  the  abdomen  be 
somewhat  pendulous,  an  abdominal  bandage,  by  supporting  the 
uterus,  will  greatly  favor  the  progress  of  this  stage.  Keeping  the 
patient  out  of  bed  has  the  further  advantage  of  preventing  her  be- 
ing unduly  anxious  for  the  termination  of  the  labor ;  and  a  little 
cheerful  conversation  will  keep  up  her  spirits,  and  obviate  the  mental 
depression  which  is  so  common.  Good  beef- tea  may  be  freely  ad- 
ministered, with  a  little  brandy  and  water  occasionally,  if  the  patient 
be  weak,  and  will  be  useful  in  supporting  her  strength. 

Vaginal  Exwrninations . — Over-frequent  vaginal  examinations  at 
this  period  should  be  avoided,  for  they  serve  no  useful  purpose,  and 


MANAGEMENT  OF  NATURAL  LABOR.  279 

are  apt  to  irritate  the  cervix.  It  will  be  necessary,  however,  to  as- 
certain the  progress  of  the  dilatation  at  intervals. 

Artificial  Rupture  of  the  Meriihro.nes.—'^\\Q,x\.  once  the  os  is  fully  di- 
lated the  membranes  may  be  artificially  ruptured  if  they  have*  not 
broken  spontaneously,  for  they  no  longer  serve  any  useful  purpose, 
and  only  retard  the  advent  of  the  propulsive  stage.  Tiiis  can  be 
easily  done  by  pressing  on  them,  when  they  are  rendered  tense  dur- 
ing a  pain,  by  some  pointed  instrument,  such  as  the  end  of  a  hair- 
pin, which  is  always  at  hand.  In  some  cases,  indeed,  it  is  even 
expedient  to  rupture  the  membranes  before  the  os  is  fully  dilated. 
Thus  it  not  infrequently  happens,  when  the  amount  of  liquor  amnii 
is  at  all  excessive,  that  the  os  dilates  to  the  size  of  a  five-shillino-. 
piece  or  more ;  but,  although  it  is  perfectly  soft  and  flaccid,  it  opens 
up  no  further  until  the  liquor  amnii  is  evacuated,  when  the  propul- 
sive pains  rapidly  complete  its  dilatation.  Some  experience  and 
judgment  are  required  in  the  detection  of  such  cases,  for  if  we  evacu- 
ated the  liquor  amnii  prematurely  the  pressure  of  the  head  on  the 
cervix  might  produce  irritation,  and  seriously  prolong  the  labor. 
This  manoeuvre  is  most  likely  to  be  useful  when  the  pains  are  strong 
and  the  os  perfectly  flaccid,  but  when  the  membranes  do  not  protrude 
through  the  os  and  effect  further  dilatation. 

It  is  sometimes  not  easy  to  ascertain  whether  the  membranes  are 
ruptured  or  not.  This  is  most  likely  to  be  the  case  when  the  head 
is  low  down,  and  the  amount  of  liquor  amnii  is  so  small  that  the 
pouch  does  not  become  prominent  during  the  pains.  A  little  care, 
however,  will  enable  us,  if  the  membranes  be  ruptured,  to  feel  the 
rugosities  of  the  scalp  covered  with  hair,  and  to  distinguish  it  from 
the  smooth  polished  surface  of  the  membranes. 

Treatment  of  the  Propulsive  Sta(fe. — After  the  evacuation  of  the 
liquor  amnii  there  is  generally  a  lull  in  the  progress  of  the  labor,  the 
pains,  however,  soon  recurring  with  increased  force  and  frequency, 
and  propelling  the  head  through  the  pelvic  cavity.  The  change  in 
the  character  of  the  pains  is  soon  appreciated  by  the  bearing  down 
efforts  by  which  they  are  accompanied,  as  well  as  by  their  increased 
length  and  intensity. 

Position  of  the  Patient  durinrj  the  Second  Stage. — It  is  now  advisa- 
ble that  the  patient  be  placed  in  bed  ;  and  in  this  country  it  is  usual 
for  her  to  lie  on  her  left  side,  with  her  nates  parallel  to  the  edge  of 
the  bed,  and  her  body  lying  across  it.  This  is  the  established  ob- 
stetric position  in  England,  and  it  would  be  useless  to  attempt  to  in- 
sist on  any  other,  even  if  it  were  advisable.  Although  the  dorsal 
position  is  preferred  on  the  Continent,  it  is  difficult  to  see  wherein 
its  advantages  consist.  It  certamly  leads  to  unnecessary  exposure 
of  the  person,  and  it  is,  on  the  whole,  less  easy  to  reach  the  patient, 
so  placed,  for  the  necessary  manipulaticms.  Moreover,  the  dorsal 
position  increases  the  risk  of  laceration  of  the  perineum,  by  bringing 
the  weight  of  the  child's  head  to  bear  more  directly  upon  it.  Thus 
Schroeder  found  that  lacerations  occurred  in  37.6  per  cent,  of  cases 
delivered  on  the  back,  as  against  24.4  per  cent,  in  other  positions. 

The  patient  usually  remains  in  bed  during  the  whole  of  this  stage, 


280  LABOR. 

and  it  is  customary  for  the  nurse  to  tie  to  the  foot  of  the  bed  a  jack- 
towel,  which  is  laid  hold  of  and  used  as  a  support  in  making  bearing 
down  efforts.  If  the  pains  be  few  and  far  between,  and  the  patient 
finds  it  more  comfortable  to  get  up  occasionally,  there  is  no  reason 
why  she  should  not  do  so.  On  the  contrary,  as  we  shall  subsequently 
see  in  treating  of  lingering  labor,  the  pains  under  such  circumstances 
are  often  increased  m  the  sitting  posture,  in  consequence  of  the 
weight  of  the  child  producing  increased  pressure  on  the  nerves  of 
the  vagina. 

Detection  of  the  Position  of  the  Head. — At  this  time  vaginal  exami- 
nation, which  should  be  more  frequently  repeated  than  in  the  first 
stage,  enables  us  to  ascertain  precisely  the  position  of  the  head,  by 
means  of  the  sutures  and  fontanelles,  as  well  as  to  watch  its  progress. 

Management  of  the  Anterior  Lip  of  Cervix  ivhen  impacted  hetiveen 
the  Head  and  Pelvis. — It  not  infrequently  happens  that  the  head 
descends  into  the  pelvis,  even  to  its  floor,  without  the  os  having 
entirely  disappeared.  The  anterior  lip  especially  is  apt  to  get  caught 
between  the  head  and  pubis,  to  become  swollen  by  the  pressure  to 
which  it  is  subjected,  and  then  to  retard  the  progress  of  the  labor. 
There  can  be  no  reasonable  objection  to  attempting  1o  prevent  this 
cause  of  delay  by  pressing  on  the  incarcerated  lip  during  the  inter- 
val of  the  pains,  so  as  to  push  it  above  the  head,  and  maintain  it 
there  during  the  pains  until  the  head  descends  below  it.  This 
manoeuvre,  if  clone  judiciously,  and  without  any  undue  roughness  or 
force,  is  certainly  not  liable  to  be  attended  by  any  of  the  evil  con- 
sequences which  many  obstetricians  have  attributed  to  it ;  it  is 
indeed  a  matter  of  common  sense  that  the  injury  to  the  cervix  is 
likely  to  be  less  if  it  be  pushed  gently  out  of  the  way,  than  if  it  be 
left  to  be  tightly  jammed  for  hours  between  the  presenting  part  and 
the  bony  pelvis.  This  mode  of  assistance  is  very  different  from  the 
digital  dilatation  of  a  rigid  cervix,  which  was  formerly  much  prac- 
tised, especially  in  Edinburgh,  in  consequence  of  the  recommendation 
of  Hamilton,  and  which  was  properly  objected  to  by  the  great  ma- 
jority of  obstetricians. 

If  the  pains  be  producing  satisfactory  progress,  no  further  inter- 
ference is  required.  The  medical  attendant  should,  however,  see  that 
the  bladder  is  evacuated  ;  and  if  it  have  not  been  so  for  some  hours, 
it  may  be  necessary  to  draw  off"  the  urine  by  the  catheter.  When- 
ever the  labor  is  lengthy,  he  should  occasionally  practise  auscultation, 
so  as  to  satisfy  himself  that  the  foetal  circulation  is  being  satisfactorily 
carried  on. 

RexjuJation  of  the  Voluntary  Beariwj-doivn  Efforts. — The  regulation 
of  the  bearing-down  efforts  at  this  time  is  of  importance.  It  is  com- 
mon for  the  nurse  to  urge  the  patient  to  help  herself  by  straining, 
and  it  is  certain  that  by  voluntarj^  exertion  of  this  kind  she  can 
materially  increase  the  action  of  the  accessory  muscles  of  parturition. 
If  the  pains  be  strong,  and  the  labor  promise  to  be  rapid,  such 
voluntary  exertions  are  not  likely  to  be  prejudicial.  On  the  other 
hand,  if  the  case  be  progressing  slowly,  they  only  unnecessarily 
fatigue  the  patient,  and  should  be  discouraged.     When  the  perineum 


MANAGEMENT  OF  NATURAL  LABOR.  28l 

is  distended  \vc  may  even  find  it  advisable  to  urge  the  patient  to 
cease  ail  voluntary  effort,  and  to  cry  out,  for  the  express  purjjose  of 
lessening  the  tension  to  which  the  perineum  is  subjected.  This  is 
the  stage  in  which  anaesthesia  is  most  serviceable,  but  its  cmploymeDt 
must  be  separately  discussed. 

Distension  of  the  Perineum. — As  the  head  descends  more  and  more 
the  perineum  becomes  distended,  and  there  is  considerable  difference 
of  opinion  amongst  accoucheurs  as  to  the  management  of  the  case 
at  this  time.  In  most  obstetric  works  the  practitioner  is  advised  to 
endeavor  to  prevent  laceration  by  the  maucjeuvre  that  is  described 
as  "  supporting  the  perineum."  By  this  is  meant,  laying  the  palm 
of  the  hand  on  the  distended  structures,  and  pressing  firmly  upon 
xhem  during  the  acme  of  the  pain,  with  the  view  of  mechanically 
preventing  their  tearing.  There  can  be  little  doubt  that  this,  or 
some  modification  of  it,  is  the  practice  now  followed  by  the  large 
majority  of  practitioners.  Of  late  years  the  evil  eftects  likely  to 
follow  it  have  been  specially  dwelt  upon  by  Graily  HeAvitt,  Leishman, 
Goodell,  and  other  writers,  who  maintain  that  by  pressure  exerted  in 
this  fashion  we  not  only  fail  to  prevent,  but  actually  favor  laceration, 
in  consequence  of  the  pressure  producing  increased  uterine  action, 
just  at  the  time  when  forcible  distension  of  the  perineum  is  likely  to 
be  hurtful.  Therefore  some  hold  that  the  perineum  ought  to  be  left 
entirely  alone,  and  that  the  head  should  be  allowed  gradually  to  dis- 
tend it,  without  any  assistance  on  the  part  of  the  practitioner. 

Much  error  may  be  traced  to  a  misconception  of  what  is  required. 
The  term  "supporting  the  perineum''  conveys  an  unquestionably 
erroneous  idea,  and  it  is  certain  that  no  one  can  prevent  laceration 
by  mechanical  support.  If  the  term  "relaxation  of  the  perineum" 
were  employed,  we  should  have  a  far  more  accurate  idea  of  what 
should  be  aimed  at,  and  if  this  be  borne  in  mind,  I  think  it  cannot 
be  questioned  that  nature  may  be  most  usefully  assisted  at  this  stage. 

Dr.  GoodeUs  Method. — Dr.  Goodell,  of  Philadelphia,  has  specially 
studied  this  subject,  and  has  recommended  a  method,  the  object  of 
which  is  to  relax  the  perineum.  His  advice  is,  that  one  or  two 
fingers  of  the  left  hand  should  be  inserted  into  the  rectum,  by  which 
the  perineum  should  be  hooked  up  and  pulled  forward  over  the  head, 
towards  the  pubis,  the  thumb  of  the  same  hand  being  placed  on  the 
advancing  head,  so  as  to  restrain  its  progress  if  needful.  I  have 
adopted  this  plan  frequently,  and  believe  that  it  admirably  answers 
its  purpose,  especially  when  the  perineum  is  greatly  distended,  and 
laceration  is  threatened.  It  must  be  admitted  that:  the  insertion  of 
the  fingers  into  the  anal  orifice,  in  the  manner  recommended,  is  re- 
pugnant both  to  the  practitioner  and  patient,  and  the  same  result 
can  be  obtained  in  a  less  unpleasant  way.  I  mention  it,  however,  to 
show  what  it  is  that  the  practitioner  must  aim  at.  If,  when  the  head 
is  distending  the  perineum  greatly,  the  thumb  and  forefinger  of  the 
right  liand  are  placed  along  its  sides,  it  can  be  pushed  gently  forward 
over  the  head  at  the  height  of  the  pain,  while  the  tips  of  the  fingers 
may,  at  the  same  time,  press  upon  the  advancing  vertex,  so  as  to 
retard  its  progress  if  advisable  (Fig.  102).  By  this  means  the  sud- 
19 


282 


LABOR. 


den  and  forcible  stretching  of  the  perineal  structures  is  prevented, 
and  the  chance  of  laceration  reduced  to  a  mini  mum,  while  nature's 
mode  of  relaxing  the  tissues,  by  dilatation  of  the  anal  orifice,  is 
favored.  This  is  very  different  from  the  mechanical  support  that  is 
usually  recommended,  and  the  less  pressure  that  is  applied  directly 


Fig.  102. 


Mode  of  effecting  relaxation  of  the  Periiienm. 


to  the  perineum  the  better.  Nor  is  it  either  needful  or  advisable  to 
sit  by  the  patient  with  the  hand  applied  to  the  perineum  for  hours, 
as  is  so  often  practised.  Time  should  be  given  for  the  gradual  dis- 
tension of  the  tissues  by  the  alternate  advance  and  recession  of  the 
head,  and  we  need  only  intervene  to  assist  relaxation  when  the 
stretching  has  reached  its  height,  and  the  head  is  about  to  be  ex- 
pelled. A  napkin  may  be  interposed  between  the  hand  and  the  skin, 
for  the  purpose  of  cleanliness.  Should  the  perineum  be  excessively^ 
touo-h  and  resistant,  assiduous  fomentation  with  a  hot  sponge  may 
be  resorted  to,  and  will  be  of  some  service  in  promoting  relaxation. 
Incision  of  the  Perineum. — When  the  tension  is  so  great  that  lace- 
ration seems  inevitable,  it  is  generally  recommended  that  a  slight 
incision  should  be  made  on  each  side  of  the  central  raphd,  with  the 
view  of  preventing  spontaneous  laceration.  This  may  no  doubt  be 
done  with  perfect  safety,  but  I  question  if  it  is  likely  to  be  of  use. 
The  idea  is  that  an  incised  wound  is  likely  to  heal  more  readily  than 
a  lacerated  one.  When,  however,  a  distended  perineum  ruptures,  its 
striictures  are  so  thinned  that  the  tear  is  always  linear ;  and,  as  a 
matter  of  fact,  the  edges  of  the  tear  are  always  as  clean,  and  as 
closely  in  apposition,  as  if  the  cut  had  been  made  with  a  knife. 
Moreover,  the  laceration  invariably  heals  perfectly,  if  only  the  edges 
be  brought  into  contact  at  once  with  one  or  two  metallic  sutures.  I 
believe  therefore,  that  Goodell  is  right  in  stating  that  incision  of  the 
perineum  is  rarely,  if  ever,  necessary,  unless  it  is  hardened  by  pre- 


MANAGEMENT  OF  NATURAL  LABOR.  283 

vious  cicatrization.  In  almost  all  first  labors,  the  fourcliette  is  torn, 
but  requires  no  treatment  of  any  kind.  In  some  cases,  do  what  we 
will,  more  or  loss  laceration  occurs,  and  the  perineum  should  always 
be  examined  after  the  expulsion  of  the  cliild,  to  see  if  any  tear  lias 
taken  place. 

Treatment  of  Lacerations.- — -If  it  has  given  way  to  any  extent,  I 
believe  that  it  is  good  practice  to  insert  one  or  two  interrupted 
sutures  of  silver  wire  or  carbolized  gut  at  once.  Immediately  after 
delivery  the  sensibility  of  the  tissues  is  deadened  by  the  distension 
to  which  they  have  been  subjected,  and  the  sutures  can  be  inserted 
with  little  or  no  pain.  It  is  quite  true  that  lacerations  of  an  inch  or 
less  will  generally  heal  perfectly  well  of  themselves ;  but  this  is  not 
invariably  the  case,  while  healing  almost  certainly  follows  if  the 
edges  be  brought  together  at  once.  In  the  severer  forms  of  lacera- 
tion, extending  baclv  to,  or  even  through  the  sphincter,  the  precaution 
is  all  the  more  necessary,  and  a  subsequent  operation  of  gravity  may 
in  this  way  be  avoided.  The  sutures  can  be  removed  Avithout  diffi- 
culty in  a  week  or  so,  when  complete  adhesion  has  taken  place. 

Expulsion  of  the  Child. — The  head,  when  expelled,  should  be  re- 
ceived in  the  palm  of  the  right  hand,  while  the  left  hand  is  placed 
upon  the  abdomen  to  follow  down  the  uterus  as  it  contracts  and 
expels  the  body.  There  is  generally  some  little  delay  after  the  ex- 
pulsion of  the  head,  and  we  should  now  see  if  the  cord  surround  the 
neck,  and,  if  it  does  so,  it  should  be  drawn  over  the  head.  The  ex- 
pulsion of  the  body  should  be  left  entirely  to  the  uterine  contrac- 
tions. If  there  be  undue  delay  we  may  endeavor  to  excite  uterine 
action  by  friction  on  the  fundus,  and  it  Avill  rarely  happen  that 
sufficient  contraction  does  not  now  come  on.  If  we  display  undue 
haste  in  withdrawing  the  bod}^,  we  run  the  risk  of  emptying  the 
uterus  while  its  tissues  are  relaxed,  and  so  favor  hemorrhage.  If, 
however,  there  seem  serious  danger  of  the  child  being  asphyxiated, 
its  expulsion  may  be  favored  by  gently  passing  the  forefinger  of  each 
hand  within  the  axillje,  and  using  traction;  but  it  is  only  very 
exceptionally  that  such  interference  is  required. 

Promotion  of  Uterine  Contraction  after  the  Birth  of  the  Child. — As 
the  uterus  contracts,  it  should  be  carefully  followed  down  through 
the  abdominal  parietes  by  the  left  hand,  Avhich  should  grasp  it  as  the 
body  is  expelled,  with  the  view  of  seeing  that  it  is  efficiently  con- 
tracted. This  is  a  point  of  vital  importance  in  preventing  hemorrhage, 
which  will  presently  be  more  especially  considered. 

Li(jature  of  the  Cord. — -As  soon  as  the  child  cries  we  may  proceed 
to  tie  and  separate  the  cord.  For  this  purjjose  the  nurse  usually 
provides  ligatures  composed  of  several  strands  of  whitey-brown 
thread;  but  tape,  or  any  other  suitable  material,  may  be  employed. 
It  is  important,  especially  if  the  cord  be  very  thick  and  gelatinous, 
to  see  that  it  is  thoroughly  compressed,  so  that  the  vessels  are  ob- 
literated, otherwise  secondary  hemorrhage  might  occur.  The  cord 
is  tied  about  an  inch  and  a  half  from  the  child,  and  it  is  usual,  though 
of  course  not  essential,  to  place  a  second  ligature  about  two  inches 
nearer  the  placental  extremity  of  the  cord.     The  latter  is,  perhaps, 


284  LABOR. 

of  some  use  by  retaining  the  blood,  and  thus  increasing  the  size,  of 
the  placenta,  and  favoring  its  more  ready  expulsion  by  uterine  con- 
traction. The  cord  is  then  divided  with  scissors  between  the  liga- 
tures, the  child  wrapped  up  in  flannel,  and  given  to  the  nurse,  or  a 
bystander,  to  hold,  while  the  attention  of  the  practitioner  is  concen- 
trated on  the  mother,  ynih  a  view  to  the  proper  management  of  the 
third  stage  of  labor. 

Im^wr lance  of  Proper  Management  of  Third  Stage. — There  is  un- 
questionably no  period  of  labor  where  skilled  management  is  more 
important,  and  none  in  which  mistakes  are  more  frequently  made. 
By  proper  care  at  this  time  the  risk  of  post-partum  hemorrhage  is 
reduced  to  a  minimum,  the  efficient  contraction  of  the  uterus  is 
secured,  the  amount  and  intensity  of  after  pains  are  lessened,  and  the 
safety  and  comfort  of  the  patient  greatly  promoted.  Moreover,  the 
general  practice,  as  to  the  management  of  this  stage,  is  opposed  to 
the  natural  mechanism  of  placental  expulsion,  and  is  far  from  being 
well  adapted  to  secure  the  important  objects  which  we  ought  to  have 
in  view.  Let  ns  see  what  i?  the  practice  usually  recommended  and 
followed,  and  then  we  shall  be  in  a  position  to  understand  in  what 
respects  it  is  erroneous.  For  this  purpose  I  cannot  do  better  than 
copy  the  directions  contained  in  one  of  our  most  deservedly  popular 
obstetric  text-books,  which  undoubtedly  expresses  the  usual  practice 
in  the  management  of  this  stage.  "When  the  binder  is  applied,  the 
patient  may  be  allowed  to  rest  a  while,  if  there  is  no  flooding  ;  after 
which,  lohen  the  titerus  contracts,  gentle  traction  may  be  made  by  the 
funis,  to  ascertain  if  the  placenta  be  detached.  If  so,  and  especially 
if  it  be  in  the  vagina,  it  may  be  removed  by  continuing  the  traction 
steadily  in  the  axis  of  the  upper  outlet  at  first,  at  the  same  time 
making  pressure  on  the  uterus."^ 

Objections  to  Ordinary  Practice. — This  may  fairly  be  taken  as  a 
sufficiently  accurate  description  of  the  practice  usually  followed.^ 
The  objections  I  have  to  make  are:  (1)  That  it  inculcates  the 
common  error  of  relying  on  the  binder  as  a  means  of  promoting 
uterine  contraction,  advising  its  application  before  the  expulsion  of 
the  placenta;  while  I  hold  that  the  binder  should  never  be  applied 
until  after  the  placenta  is  expelled,  and  not  even  then,  unless  the 
uterus  is  perfectly  and  permanently  contracted.  (2)  That  it  teaches 
that  traction  on  'the  cord  should  be  used  as  a  means  of  withdraw- 
ing the  placenta ;  whereas  the  uterus  itself  should  be  made  to  expel 
the  after-birth,  and,  in  nineteen  cases  out  of  twenty,  the  finger  need 
never  be  introduced  into  the  vagina  after  the  birth  of  the  child,  nor 
the  cord  touched.  This  may  seem  an  exaggerated  statementto  those 
who  have  accustomed  themselves  to  the  usual  method  of  dealing  Avith 
the  placenta;  but  I  feel  confident  that  all  who  have  learnt  the  method 
of  expression  of  the  placenta  wcnild  testify  to  its  accuracy. 

Expression  of  the  Placenta.— The  cardinal  point  to  bear  in  mind  is, 
that  the  placenta  should  be  expelled  from  the  uterus  by  a  vis  a  tergo, 

'  Churchill's  Theory  and  Practice  of  Midwifery,  p.  Ifi2. 

2  This  practice  is  further  illustrated  by  the  annexed  diagram,  contained  in  most 


MANAGEMENT  OF  NATURAL  LABOR. 


285 


not  drawn  out  by  a  vis  a  fronte.  That  uterine  pressure  after  the 
birth  of  the  child  has  been  recommended  by  many  English  writers 
is  certain,  and  the  Dublin  school  especially  have  dwelt  on  its  import- 
ance as  a  preventive  of  post-partum  hemorrhage ;  but  the  distinct 
enunciation  of  the  doctrine  that  the  placenta  should  be  pressed,  and 
not  drawn,  out  of  the  uterus,  we  owe  to  Credd  and  other  German 
writers;  and  it  is  only  of  late  years  that  this  practice  has  become  at 
all  common.  Those  who  have  not  seen  placental  expression  prac- 
tised, find  it  difficult  to  understand  that,  in  the  large  majority  of 
cases,  the  uterus  may  be  made  to  expel  the  placenta  out  of  the  va- 
gina ;  but  such  is  unquestionably  the  fact.  A  little  practice  is  no 
doubt  necessary  to  effect  this  satisfactorily ;  but  when  once  the 
knack  has  been  learnt,  there  is  little  difficulty  likely  to  be  ex- 
perienced. 

Im'portance  of  not  Removing  the  Placenta  Hurriedly. — Before  de- 
scribing the  method  of  placental  expression,  a  Avord  of  caution  may 
be  said  against  undue  haste  in  attempting  expression  of  the  placenta, 
a  mistake  that  is  often  made,  and  which,  I  believe,  tends  to  increase 
the  risk  of  post-partum  hemorrhage.  So  long  as  we  satisfy  our- 
selves that  the  uterus  is  fairly  contracted,  so  as  to  avoid  the  possi- 
bility of  its  distension  with  blood,  a  certain  delay  after  the  birth  of 
the  child  is  useful,  from  its  giving  time  for  coagula  to  form  within 
the  uterine  sinuses,  by  which  their  open  mouths  are  closed  up.  The 
importance  of  this  point  has  been  specially  dwelt  upon  by  McClin- 
tock,  who  lays  down  the  rule  that  15  or  20  minutes  should  be  allowed 
to  elapse,  after  the  birth  of  the  child,  before  any  attempt  to  remove 

obstetric  works,  which  represents  the  accoucheur  as  withdrawing  the  placenta  by 
traction,  and  which  I  insert  as  an  illustration  of  what  ought  not  to  be  done  (Fig.  103), 

Fig.  103. 


Usual  Method  of  Removing  the  Placenta  hy  Traction  on  the  Cord. 


LABOR. 


the  after-birtli  is  made.  This  is  a  good  and  safe  practical  rule,  as  it 
gives  ample  time  for  the  complete  detachment  of  tlie  placenta,  and 
the  coagulation  of  the  blood  in  tlie  uterine  sinuses. 

Mode  of  Effecting  Expression  of  the  Placenta. — During  this  inter- 
val the  practitioner  or  nurse  should  sit  by  the  bedside,  with  the  hand 
on  the  uterus  to  secure  contraction  and  prevent  distension  ;  but  not 
kneading  or  forcibly  compressing  it.  When  we  judge  that  a  suffi- 
cient time  has  elapsed,  we  may  proceed  to  effect  expulsion.  For 
this  purpose  the  fundus  should  be  grasped  in  the  hollow  of  the  left 
hand,  the  ulnar  edge  of  the  hand  being  well  pressed  down  behind 
the  fundus,  and  when  the  uterus  is  felt  to  harden,  strong  and  firm  pres- 
sure should  be  made  downwards  and  backwards  in  the  axis  of  the 
pelvic  brim.  If  this  manoeuvre  be  properly  carried  out,  and  suffi- 
ciently firm  pressure  made,  in  almost  every  case  the  uterus  may  be 
made  to  expel  the  placenta  into  the  bed,  along  with  any  coagula  that 
may  be   in  its  cavity  (Fig.  104).     The   uterine  surface  of  the  pla- 

FiG.  101. 


IUu»trating  Expression  of  the  Placenta. 

centa  is  generally  expelled  first,  as  is  represented  in  the  diagram,  the 
cord  being  within  the  membranes ;  whereas  the  fcetal  surface,  and 
root  of  the  cord,  are  the  parts  which  appear  first  when  the  placenta 
is  removed  by  traction  (Fig.  103).  If  we  do  not  succeed  at  the  first 
effort,  which  is  rarely  the  case  if  extrusion  be  not  attempted  too 
soon  after  the  birth  of  the  child,  we  may  wait  until  another  contrac- 
tion takes  place,  and  then  reapply  the  pressure.  I  repeat  that,  after 
a  little  practice,  the  placenta  may  be  entirely  expelled  in  this  way, 
in  nineteen  cases  out  of  twenty,  without  even  touching  the  cord,^ 
and  the  bugbear  of  retained  placenta  will  cease  to  be  a  source  of 
dread. 

Management  of  the  Memhranes.—^hov^d  we  fail  in  causing  the 
uterus  to  expel  the  placenta,  a  vaginal  examination  may  be  made, 
and,  if  the  placenta  be  found  lying  entirely  in  the  vagina,  it  may  be 


MANAGEMENT    OF    NATUllAL    LABOR.  287 

carefully  withdrawn.  If,  liowever,  the  cord  can  be  traced  up  through 
the  OS,  showing  that  the  placenta  is  still  within  the  uterine  cavity, 
we  must  again  resort  to  pressure  to  effect  its  expulsion,  and  not  at- 
tempt to  withdraw  it  by  traction.  Such  cases  may  fairly  be  classed 
as  retained  placenta,  but  they  should  be  very  rarely  met  with,  and 
are  discussed  elsewhere.  When  they  do  occur  often  in  the  hands  of 
the  same  practitioner,  it  is  fair  to  conclude  that  he  has  not  properly 
acquired  the  art  of  managing  this  stage  of  labor.  Generally  speak- 
ing, the  placenta  should  be  expelled  within  twenty  minutes  afte-r  the 
birth  of  the  child ;  but  no  doubt,  in  the  large  majority  of  cases, 
ex]3ulsion  might  be  effected  sooner  were  it  advisable  to  attempt  it. 

Wlien  the  mass  of  the  placenta  is  expelled,  the  membranes  gene- 
rally still  remain  in  the  vagina,  and  they  should  be  twisted  into  a 
rop?,  and  very  gently  withdrawn,  so  as  not  to  leave  any  portion 
behind.  This  is  a  precaution  the  importance  of  which  I  would 
strongly  urge,  for  I  believe  that  the  chance  of  part  of  the  membranes 
being  torn  off  and  left  in  utero  is  the  one  objection  to  the  method 
recommended.  With  due  care,  liowever,  this  accident  may  be 
avoided,  and  the  risk  will  be  lessened  if  the  placenta  is  received  into 
the  palm  of  the  right  hand,  on  expression,  so  as  to  avoid  any  strain 
on  the  membranes. 

Compression  of  the  Uterus  after  the  Expulsion  of  the  Placenta.— The 
duties  of  the  medical  attendant  are  not  even  now  over.  For  at  least 
ten  minutes  after  the  extrusion  of  the  placenta,  he  should  keep  his 
hani  on  the  firmly  contracted  uterus,  gently  kneading  it,  without 
any  force,  for  the  purpose  of  promoting  firm  and  equable  contraction, 
and  causing  it  to  throw  off  any  coagula  that  may  form  in  its  cavity. 

Administration  of  Ergot  of  Rye. — The  subsequent  comfort  and  safety 
of  the  patient  may  be  promoted  by  administering,  at  this  time,  a  full 
dose  of  ergot  of  rye,  such  as  a  drachm,  or  more,  of  the  liquid  extract. 
The  property  possessed  by  this  drug  of  producing  tonic  and  persistent 
contraction  of  the  uterine  fibres,  which  renders  it  of  doubtful  utility 
as  an  oxytocic  during  labor,  is  of  special  value  after  delivery,  when 
such  contraction  is  precisely  what  we  desire.  I  have  long  been  in 
the  habit  of  administering  the  drug  at  this  period,  and  believe  it  to 
be  of  great  value,  not  only  as  a  prophylactic  against  hemorrhage, 
but  as  a  means  of  lessening  after-pains. 

Application  of  the  Binder.— -When  we  are  satisfied  that  the  uterus 
is  permanently  contracted  we  may  apply  the  binder,  but  this  should 
rarely  be  done  until  at  least  half  an  hour  after  the  birth  of  the  child. 
The  soiled  clothes  should  be  gently  withdrawn  from  under  the 
patient,  moving  her  as  little  as  possible,  and  the  binder  should  be, 
at  the  same  time,  slipped  under  the  body,  taking  care  that  it  is 
passed  well  below  the  hips,  so  as  to  secure  a  firm  hold.  No  kind  of 
bandage  is  better  than  a  piece  of  stout  jean,  of  suflicient  breadth  to 
extend  from  the  trochanters  to  the  ensiform  cartilage ;  a  jack-towel 
or  bolster  slip  answers  the  purpose  Yery  well.  These  are  preferable, 
at  any  rate  at  first,  to  the  shaped  binders  that  are  often  iised.  One 
or  two  folded  napkins  are  generally  placed  over  the  uterus,  so  as  to 
form  a  pad  to  keep  up  pressure.     Once  in  position,  the  binder  is 


288  LABOR. 

palled  tight,  and  fastened  by  pins.  The  utilit}^  of  careful  bandaging 
after  delivery  can  scarcely  be  doubted,  although  some  years  ago  it 
became  the  fashion  to  dispense  with  it.  It  gives  a  comfortable  sup- 
port to  the  lax  abdominal  walls,  keeps  up  a  certain  amount  of  pres- 
sure on  the  uterus,  and  tends  to  restore  the  figure  of  the  patient. 
After  the  bandage  is  applied,  a  warm  napkin  should  be  placed  on  the 
vulva,  as  a  means  of  estimating  the  quantity  of  the  discharge  and 
the  patient  may  be  allowed  to  rest. 

After-treatment. — Unless  the  labor  have  been  very  long  and  fatigu- 
ing, an  opiate,  often  exhibited  as  a  matter  of  routine,  is  unadvisable; 
although  it  may  be  well  to  leave  one  with  the  nurse,  to  be  given  if 
the  patient  cannot  sleep,  or  if  the  after-pains  be  very  troublesome. 
The  practitioner  may  now  leave  the  room,  but  not  the  house,  and  at 
least  an  hoar  should  elapse  after  delivery  before  he  takes  his  depart- 
ure. Before  doing  so  he  should  visit  the  patient,  inspect  the  napkin 
to  see  that  there  is  not  too  much  discharge,  and  satisfy  himself  that 
the  uterus  is  contracted,  and  not  distended  with  coagula.  He  should 
also  count  the  pulse,  which,  if  the  patient  be  progressing  satisfac- 
torily, will  be  found  at  its  normal  average.  If,  however,  it  be  beat- 
ing over  100  per  minute,  he  should  on  no  account  leave,  for  such  a 
rapidity  of  the  circulation  renders  it  extremely  probable  that  hemor- 
rhage is  impending.  This  is  a  good  practical  rule,  laid  down  by 
M'Clintock  in  his  excellent  paper  "On  the  Pulse  in  Child-bed," 
attention  to  which  may  often  save  the  patient  from  disastrous  con- 
sequences. 

Before  leaving,  the  practitioner  should  see  that  the  room  is  dark- 
ened, all  b3^standers  excluded,  and  the  patient  left  as  quiet  as  possible 
to  recover  from  the  shock  of  labor. 


CHAP  TEE    IV. 

ANESTHESIA  IN  LABOE. 

A  FEW  words  may  be  said  as  to  the  use  of  ancesthetics  during 
labor,  a  practice  which  has  become  so  universal  that  no  argument  is 
required  to  establish  its  being  a  perfectly  legitimate  means  of  as- 
suaging the  suiferings  of  childbirth.  Indeed,  the  tendency  in  the 
present  day  is  in  the  opposite  direction  ;  and  a  common  error  is  the 
administration  of  chloroform  to  an  extent  which  materially  interferes 
with  the  uterine  contractions,  and  predisposes  to  subsequent  post- 
partum hemorrhage. 

Af/ents  Employed. — Practically  speaking  the  only  agent  hitherto 
employed  in  this  country  is  chloroform,  although  the  bi-chloride  of 
methylene,  and  ether,  have  been  occasionally  tried.     Of  late  years, 


ANiESTHESIA    IN    LABOR.  289 

chloral  has  been  oxtensively  used  by  some  ;  and  as  I  believe  it  to  be 
an  agent  of  very  great  value,  I  shall  lirst  indicate  the  cij'curnstances 
under  which  it  ma}'-  be  employed. 

Chloral. — The  peculiar  value  of  chloral  in  labor  is,  that  it  may  be 
safely  administered  at  a  time  when  chloroform  cannot  be  generally 
employed.  The  latter,  while  it  annuls  suffering,  very  frequently 
tends,  in  a  marked  degree,  to  diminish  uterine  action.  This  is  a 
familiar  observation  to  all  who  have  employed  it  much  during  labor, 
as  the  diminution  of  the  force  and  intensity  of  the  pains,  and  the 
consequent  retardation  of  the  labor,  often  oblige  us  to  suspend  its  in- 
halation, at  least  temporarily.  Indeed,  this  very  property  of  annul- 
ling uterine  action  is  one  of  its  most  valuable  qualities  in  obstetrics, 
as  in  certain  cases  of  turning.  For  such  purposes  it  is  necessary  to 
give  it  to  the  surgical  extent,  which  we  endeavor  to  avoid  when  it  is 
used  simply  to  lessen  the  suffering  of  ordinary  labor.  Still  it  is  not 
always  easy  to  limit  its  action  in  this  way,  and  thus  it  very  frequently 
does  more  than  we  wish.  Such  diminution  in  the  intensity  of  uterine 
contraction  is  comparatively  of  less  consequence  in  the  propulsive 
stage,  and  it  is  generally  more  than  counterbalanced  b7  the  relief  it 
affords.  In  the  first  stage  it  is  otherwise,  and,  practically  speaking, 
chloroform  is  generally  not  admissible  until  the  head  is  in  the  pelvic 
cavity. 

Chloral  on  the  other  hand,  has  no  such  relaxing  effects  on  uterine 
contraction.  It  cannot,  it  is  true,  compete  with  chloroform  in  its  power 
of  relieving  pain,  but  it  produces  a  drowsy  state  in  which  the  pain  is 
not  felt  nearly  so  acutely  as  before.  It  is,  therefore,  in  the  first  stage 
of  labor,  while  the  pains  are  cutting  and  grinding,  and  during  the 
dilatation  of  the  cervix,  that  it  finds  its  most  useful  application.  It 
is  especially  valuable  in  those  cases,  so  frequently  met  Avith  in  the 
upper  classes,  in  which  the  pains  produce  intolerably  acute  suffering, 
with  but  little  effect  on  the  progress  of  the  labor.  In  them  the  os  is 
often  thin  and  rigid,  and  the  pains  very  frequent  and  acute,  but  little 
or  no  dilatation  is  effected.  When  the  patient  is  brought  under  the 
influence  of  chloral,  however,  the  pains  become  less  frequent  but 
stronger,  nervous  excitement  is  calmed,  and  the  dilatation  of  the 
cervix  often  proceeds  rapidly  and  satisfactorily.  Indeed  I  know  of 
nothing  which  answers  so  well  in  cases  of  rigid,  undilatable  cervix, 
and  I  believe  its  administration  to  be  far  more  effective,  under  such 
circumstances,  than  any  of  the  remedies  usually  employed. 

Object  and  Mode  of  Administration. — The  object  is  to  produce  a 
somnolent  condition,  which  shall  be  protracted  as  long  as  possible, 
Fo.r  this  purpose  15  grains  of  chloral  may  be  administered  every 
twenty  minutes,  until  three  doses  are  given.  This  generally  suffices 
to  produce  the  desired  effect.  The  patient  becomes  very  drowsy, 
dozes  between  the  pains,  and  wakes  up  as  each  contraction  com- 
mences. It  may  be  necessary  to  give  a  fourth  dose,  at  a  longer  in- 
terval, say  an  hour  after  the  third  dose,  to  keep  up  and  prolong  the 
soporific  action,  but  this  is  seldom  necessary,  and  I  have  rarely  given 
more  than  a  drachm  of  chloral  during  the  entire  progress  of  labor. 
Another  advantage  of  this  treatment  is  that,  while  it  does  not  inter- 


290  LABOR. 

fere  witli  the  use  of  cliloroform  in  the  second  stage,  it  renders  it 
necessary  to  give  less  than  otherwise  "vvoukl  be  called  for,  and  thus 
its  action  can  be  more  easily  kept  within  bounds.  On  the  whole, 
therefore,  I  am  inclined  to  consider  chloral  a  very  valuable  aid  in  the 
management  of  labor,  and  believe  that  it  is  destined  to  be  much  more 
extensively  used  than  is  at  present  the  case.  So  far  as  my  experi- 
ence has  yet  gone  I  have  not  met  with  any  symptoms  which  have  led 
me  to  think  that  it  has  produced  bad  effects ;  and  I  have  known 
many  patients  sleep  quietly  through  labor,  without  expressing  any 
excessive  suffering,  or  asking  for  chloroform,  who,  under  ordinary 
circumstances,  would  have  been  most  urgently  calling  for  relief.  It 
occasionally  happens  that  the  patient  cannot  retain  the  chloral  from 
its  tendency  to  produce  sickness ;  it  may  then  be  readily  given  per 
rectum  in  the  form  of  enema. 

Chloroform.- — Generally  speaking,  we  do  not  think  of  giving  chloro- 
form until  the  os  is  fully  dilated,  the  head  descending,  and  the  pains 
becoming  propulsive.  It  has  often,  indeed,  been  administered  earlier, 
for  the  purpose  of  aiding  the  dilatation  of  a  rigid  cervix,  and  there 
is  no  doubt  that  it  often  succeeds  well  when  employed  in  this  way ; 
but  I  have  already  stated  my  belief  that  chloral  answers  this  purpose 
better. 

Should  only  ■  he  given  dnring  the  Pains. — There  is  one  cardinal 
rule  to  be  remembered  in  giving  chloroform  during  the  propulsive 
stage,  and  that  is,  that  it  should  be  administered  intermittently,  and 
never  continuously.  When  the  pain  comes  on  a  few  drops  may  be 
scattered  over  a  Skinner's  inhaler,  which  affords  one  of  the  best 
means  of  administering  it  in  labor,  or  placed  within  the  folds  of  a 
handkerchief  twisted  into  the  form  of  a  cone.  During  the  acme  of 
the  pain  the  patient  inhales  it  freely,  and  at  once  experiences  a  sense 
of  great  relief;  and,  as  soon  as  the  pain  dies  away,  the  inhaler  should 
be  removed.  In  the  interval  between  the  pains  the  effect  of  the  drug 
passes  off,  so  that  the  higher  degree  of  ancesthesia  should  never  be 
produced.  Indeed,  when  properly  given,  consciousness  should  not 
be  entirely  abolished,  and  the  patient,  between  the  pains,  should  be 
able  to  speak,  and  understand  what  is  said  to  her.  This  intermittent 
administration  constitutes  the  peculiar  safety  of  chloroform  admin- 
istered in  labor,  and  it  is  a  fortunate  circumstance  that,  as  yet,  there 
is,  I  believe,  no  case  on  record  of  death  during  the  inhalation  of 
chloroform  for  obstetric  purposes.  This  is  obviously  due  to  the 
effect  of  each  inhalation  passing  off  before  a  fresh  dose  is  admin- 
istered. 

The  effect  on  the  pains  should  be  carefully  watched.  If  they 
become  very  materially  lessened  in  force  and  frequency,  it  may  be 
necessary  to  stop  the  inhalation  for  a  short  time,  commencing  again 
when  the  pains  get  stronger,  which  effect  may  be  often  completely 
and  easily  prevented  by  mixing  the  chloroform  with  about  one-third 
of  absolute  alcohol,  which,  originally  recommended,  I  believe,  by 
Dr.  Sansom,  increases  the  stimulating  effects  of  the  chloroform,  and 
thus  diminishes  its  tendency  to  produce  undue  relaxation.  The 
amount  administered  must  vary,  of  course,  with  the  peculiarities  of 


ANESTHESIA    IN    LABOR.  291 

each  individual  case  and  the  effect  produced,  but  it  need  never  be 
large.  As  the  head  distends  the  perineum,  and  the  pains  get  very 
strong  and  forcing,  it  may  be  given  more  ireely  and  to  the  extent  of 
inducing  even  complete  insensibility  just  before  the  child  '.s  born. 

Ether  as  a  /Substitute  for  Chloroform. — In  cases  in  which  chloroform 
has  lessened  the  force  of  the  pains  ether  may  be  given  instead  with 
great  advantage.  It  certainly  often  acts  well  when  chloroform  is 
inadmissible  on  account  of  its  effects  on  the  pains,  and,  so  far  as  my 
experience  goes,  it  has  not  the  property  of  relaxing  the  uterus,  but, 
on  the  contrary,  has  sometimes  seemed  to  me  distinctly  to  intensify 
the  pains.  Of  late  I  have  used  a  mixture  of  one  part  of  absolute 
alcohol,  two  of  chloroform,  and  three  of  ether.  This  is  less  disagree- 
able than  ether,  and  has  nut  the  over-relaxing  effects  of  chloroform. 

Precautions. — Bearing  in  mind  the  tendency  of  chloroform  to  pro- 
duce uterine  relaxation,  more  than  ordinary  precautions  should 
always  be  taken  against  post-partuni  hemorrhage  in  all  cases  in 
which  it  has  been  freely  administered. 

In  cases  of  operative  midwifery  it  is  often  given  to  the  extent  ot 
producing  complete  aneesthesia.  In  all  such  cases  it  should  be  admin- 
istered, when  possible,  by  another  medical  man,  and  not  by  the 
operator,  because  the  giving  of  chloroform  to  the  surgical  degree 
requires  the  undivided  attention  of  the  administrator,  and  no  man 
can  do  this  and  operate  at  the  same  time.  I  once  learnt  an  import- 
ant lesson  on  this  point.  I  had  occasion  to  apply  the  forceps  in  the 
case  of  a  lady  who  insisted  on  having  chloroform.  When  commenc- 
ing the  operation  I  noticed  some  suspicious  appearances  about  the 
patient,  who  was  a  large  stout  Avoman,  with  a  feeble  circulation.  I 
therefore  stopped,  allowed  her  to  regain  consciousness,  and  delivered 
her  without  anaesthesia,  much  to  her  own  annoyance.  Just  one  month 
after  labor  she  went  to  a  dentist  to  have  a  tooth  extracted,  and  took 
chloroform,  during  the  inhalation  of  which,  she  died.  This  impressed 
on  my  mind  the  lesson  that  no  man  can  do  two  things  at  the  same 
time.  The  partial  unconsciousness  of  incomplete  anaesthesia,  in 
which  the  patient  is  restless  and  tossing  about,  renders  the  applica- 
tion of  forceps,  as  well  as  all  other  operations,  very  difficult.  There- 
fore, "unless  the  patient  can  be  completely  and  fully  ansesthetized,  it 
is  better  to  operate  without  chloroform  being  given  at  all, 

[In  the  United  States  chloroform  is  rarely  used  in  obstetric  practice, 
as  compared  with  pure  sulphuric  ether,  such  as  that  prepared  by  Dr. 
Squibb,  of  New  York ;  and  anaesthesia  is  much  less  frequently  "prac- 
tised than  it  was  soon  after  its  introduction.  With  some  Avomen 
ether  acts  as  a  stimulant,  increasing  their  power  of  expulsion,  while 
at  the  same  time  the  suffering  is  greatly  lessened ;  the  whole  pro- 
cess of  labor  is  perfect ;  the  placenta  extruded  almost  without 
blood,  and  there  is  no  subsequent  uterine  relaxation.  But  unfortu- 
nately such  cases  are  exceptional.  With  some  patients  the  angesthetic 
produces  a  species  of  intoxication,  with  hysterical  excitement,  and 
the  pains,  which  are  at  first  diminished,  at  last  cease  entirely,  or  are 
rendered  of  no  value,  and  the  ether  has  to  be  withheld,  as  I  have 
frequently  seen.     Some  women  complain  that  they  have  a  night- 


292  LABOR. 

mare,  or  are  made  to  "feel  wild,"  and  are  not  relieved  of  pain,  nnd 
request  to  have  the  anaesthetic  withheld.  But  the  chief  cause  for 
the  infrequent  resort  to  ether  has  been  the  production  of  uterine 
inertia  after  delivery,  and  consequent  post-partum  hemorrhage.  In 
turning,  the  remedy  is  for  the  time  important,  but  the  delivery  need 
not  be  completed  under  it.  The  use  of  fluid  ext.  ergot  is  a  valuable 
prophylactic,  but  more  to  be  relied  upon  in  most  instances  where 
there  has  been  no  angesthesia. — Ed.] 


CHAPTER   Y. 

PELVIC   PRESENTATIONS. 

Under  the  head  of  'pelvic  presentations  it  is  customary  to  include 
all  cases  in  which  any  part  of  the  lower  extremities  of  the  child  pre- 
sents. By  some  these  are  further  subdivided  into  breech^  footling,  and 
knee  presentations ;  but,  although  it  is  of  consequence  to  be  able  to 
recognize  the  feet  and  the  knee  when  they  present,  so  far  as  the 
mechanism  and  management  of  delivery  are  concerned,  the  cases  are 
identical,  and,  therefore,  may  be  most  conveniently  considered  to- 
gether. 

Frequency. — Presentations  coming  under  this  head  are  far  from 
uncommon  ;  those  in  which  the  breech  alone  occupies  the  pelvis  are 
met  with,  according  to  Churchill,  once  in  52  labors,  while  Rams- 
botham  estimates  that  it  presents  more  frequently,  viz.,  once  in  38.8 
labors.  Footling  presentations  occur  only  once  in  92  cases.  They 
are  probably  often  the  mere  conversion  of  original  breech  presenta- 
tions, the  feet  having  come  down  during  the  labor,  either  in  conse- 
quence of  the  sudden  escape  of  the  liquor  amnii,  when  the  breech 
was  still  freely  movable  above  the  brim,  or  from  some  other  cause. 
Knee  presentations  are  extremely  rare,  as  may  be  readily  understood 
if  it  be  borne  in  mind  that  to  admit  them  the  thighs  must  be  ex- 
tended, hence  the  vertical  measurement  of  the  child  must  be  greatly 
increased,  and  therefore  it  could  not  be  readily  accommodated  within 
the  uterine  cavity,  unless  of  unusually  small  size.  As  a  matter  of 
fact,  Mme.  La  Chapelle  found  only  one  knee  presentation  in  upwards 
of  3000  cases. 

Causes. — The  causes  of  pelvic  presentations  are  not  known.  They 
are  probably  the  same  as  those  Avhich  produce  other  varieties  of  mal- 
presentations ;  and  it  is  not  unlikely  that,  in  certain  women,  there 
may  be  some  peculiarity  in  the  shape  of  the  uterine  cavity  which 
favors  their  production.  It  Avould  be  difficult  otherwise  to  explain 
such  a  case  as  that  mentioned  by  Velpeau,  in  which  the  breech  pre- 
sented in  six  labors. 


PELVIC    PRESENTATIONS.  298 

Prognosis. — The  results,  as  regards  the  mother,  are  in  no  way  more 
unfavorable  than  in  vertex  presentation.  The  first  stage  of  the  labor 
is  generally  tedious,  since  the  large  rounded  mass  of  the  breech  does 
not  adapt  itself  so  well  as  the  head  to  the  lower  segment  of  the  uterus, 
and  dilatation  of  the  cervix  is  consequently  apt  to  be  retarded.  The 
second  stage  is,  however,  if  anything,  more  rapid  than  in  vertex 
cases ;  and  even  when  it  is  protracted,  the  soft  breech  does  not  pro- 
duce such  injurious  pressure  on  the  maternal  structures  as  the  hard 
and  unyielding  head. 

The  Infantile  Mortality  in  Pelvic  Presentations. — The  result  is  very 
different  as  regards  the  child.  Dubois  calculated  that  1  out  of  11 
children  was  still-born.  Churchill  estimates  the  mortality  as  much 
higher,  viz.,  1  in  3^.  The  latter  certainly  indicates  a  larger  num- 
ber of  still-births  than  is  consistent  with  the  experience  of  most 
practitioners,  and  more  than  should  occur  if  the  cases  be  properly 
managed ;  but  there  can  be  no  doubt  that  the  risk  to  the  child  is, 
even  under  the  most  favorable  circumstances,  very  great.  Even  when 
the  child  is  not  lost  it  may  be  seriously  injured.  Dr.  Ruge  has  tabu- 
lated a  series  of  29  cases  in  which  there  were  found  to  be  fractures  of 
bones  or  other  injuries.^ 

Causes  of  Foetal  Mortality. — The  chief  source  of  danger  is  pressure 
on  the  umbilical  cord,  in  the  interval  elapsing  between  the  birth  of 
the  body  and  the  head.  At  this  time  the  cord  is  very  generally  com- 
pressed between  the  head  of  the  child  and  the  pelvic  walls,  so  that 
circulation  in  its  vessels  is  arrested.  Hence  the  aeration  of  the  foetal 
blood  cannot  take  place  ;  and,  pulmonarj^  respiration  not  having  been 
yet  established,  the  child  dies  asphyxiated.  There  are  other  condi- 
tions present  which  tend,  although  in  a  minor  degree,  to  produce  the 
same  result.  One  of  these  is  that  the  placenta  is  probably  often 
separated  by  the  uterine  contractions  when  the  bulk  of  the  body  is 
being  expelled,  as,  indeed,  takes  place,  under  analogous  circum- 
stances, when  the  vertex  presents ;  the  necessary  result  being  the 
arrest  of  placental  respiration.  Joulin  thinks  that  the  same  effect 
may  be  produced  by  the  compression  of  the  placenta  between  the 
contracted  uterus  and  the  hard  mass  of  the  foetal  skull.  Probably 
all  these  causes  combine  to  arrest  the  functions  of  the  placenta  ;  and, 
if  the  delivery  of  the  head,  and  consequently  the  establishment  of 
pulmonary  respiration,  be  delayed,  the  death  of  the  child  is  almost 
inevitable.  The  corollary  is  that  the  danger  to  the  child  is  in  direct 
proportion  to  the  length  of  time  that  elapses  between  the  birth  of 
the  body  and  that  of  the  head. 

The  risk  to  the  child  is  greater  in  footling  than  in  breech  cases, 
because  in  the  former  the  maternal  structures  are  less  perfectly  di-- 
lated,  in  consequence  of  the  small  size  of  the  feet  and  thighs,  and, 
therefore,  the  birth  of  the  head  is  more  apt  to  be  delayed. 

Diagnosis. — Inasmuch  as  the  long  axis  of  the  child  corresponds 
with  the  long  axis  of  the  uterus,  in  pelvic  as  in  vertex  presentations, 
there  is  nothing  in  the  shape  of  the  uterus  to  arouse  suspicion  as  to 

'  Bui.  f^en.  de  Thbrap.,  August,  1875. 


294  LABOR. 

the  character  of  the  case.  Still,  it  is  often  sufficiently  easy  to  recog- 
nize a  pelvic  presentation  by  abdominal  examination,  if  we  have 
occasion  to  make  one.  The  facility  with  which  it  may  be  done  de- 
pends a  good  deal  on  the  individual  patient.  If  she  be  not  very 
stout,  and  if  the  abdominal  parietes  be  lax  and  non-resistant,  we 
shall  generally  be  able  to  feel  the  roilnd  head  at  the  U23per  part  of 
the  uterus  much  firmer,  and  more  defined  in  outline  than  the  breech. 
The  conclusion  will  be  fortified  if  we  hear  the  foetal  heart  beating  on 
a  level  with,  or  above,  the  umbilicus.  The  greater  resistance  on  one 
side  of  the  abdomen  will  also  enable  us  to  decide,  with  tolerable  ac- 
curacy, to  which  side  the  back  of  the  child  is  placed.  Information 
thus  acquired  is,  at  the  best,  uncertain;  and  we  can  never  be  quite 
sure  of  the  existence  of  a  pelvic  presentation  until  we  can  corrobo- 
rate the  diagnosis  by  vaginal  examination. 

Besults  of  Vaginal  Examination. — The  first  circumstance  to  ex- 
cite suspicion  on  examination  |jer  va.ginam^  even  when  the  os  is  un- 
dilated,  is  the  absence  of  the  hard  globular  mass  felt  through  the 
lower  segment  of  the  uterus,  which  is  so  characteristic  of  vertex 
presentations.  When  the  os  is  sufficiently  open  to  allow  the  mem- 
branes to  protrude,  although  the  presenting  part  is  too  high  up  to  be 
within  reach,  we  may  be  struck  with  the  peculiar  shape  of  the  bag 
of  membranes,  which,  instead  of  being  rounded,  projects  a  consider- 
able distance  through  the  os,  like  the  finger  of  a  glove.  This  is  a 
peculiarity  met  with  in  all  malpresentations  alike,  and  is,  indeed, 
much  less  distinct  in  breech  than  in  footling  presentations,  because 
in  the  former  the  membranes  are  more  stretched,  just  as  they  are  in 
vertex  cases.  When  the  membranes  ruptu.re,  instead  of  the  waters 
dribbling  away  by  degrees,  they  often  escape  with  a  rush,  in  conse- 
quence of  the  pelvic  extremity  not  filling  up  the  lower  part  of  the 
uterus  so  accurately  as  the  head,  which  acts  as  a  sort  of  ball-valve, 
and  prevents  the  sudden  and  complete  discharge  of  the  Avaters. 

Diagnosis  of  the  Breech. — Often,  on  first  examining,  even  when  the 
membranes  are  ruptured,  the  presentation  is  too  high  up  to  be  made 
out  accurately.  All  that  we  can  be  certain  of  is,  that  it  is  not  the 
head ;  and  the  case  must  be  carefully  watched,  and  examinations 
frequently  repeated,  until  the  precise  nature  of  the  presentation  can 
be  established.  If  the  breech  present,  the  finger  first  impinges  on  a 
round,  soft  prominence,  on  depressing  which  a  bony  protuberance, 
the  trochanter  major,  can  be  felt.  On  passing  the  finger  upwards  it 
reaches  a  groove,  beyond  which  a  similar  fleshy  mass,  the  other 
buttock,  can  be  felt.  In  this  groove  various  characteristic  points, 
diagnostic  of  the  presentation,  can  be  made  out.  Towards  one  end 
we  can  feel  the  movable  tip  of  the  coccyx,  and  above  it  the  hard 
sacrum,  with  rough  projecting  prominences.  These  points,  if  accu- 
rately made  out,  are  quite  characteristic,  and  resemble  nothing  in 
any  other  presentation.  In  front  there  is  the  anus,  in  which  it  is 
sometimes,  but  by  no  means  always,  possible  to  insert  the  tip  of  the 
finger.  If  this  can  be  done  it  is  easy  to  distinguish  it  from  the 
mouth,  with  which  it  might  be  confounded,  by  observing  that  the 
hard  alveolar  ridges  are  not  contained  within  it.     Still  more  in  front 


PELVIC    PRESENTATIONS.  295 

we  may  find  the  genital  organs,  the  scrotum  in  male  children  being 
often  much  swollen  if  the  labor  has  been  protracted.  Thus  it  is  often 
possible  to  recognize  the  sex  of  the  child  before  birth. 

Differential  Vicujuosis. — The  breech  might  be  mistaken  for  the  face, 
especially  if  the  latter  be  much  swollen  ;  but  this  mistake  can  readily 
be  avoided  by  feeling  the  spinous  processes  of  the  sacrum. 

The  knee  is  recognized  by  its  having  two  tuberosities  with  a  de- 
pression between  them.  It  might  be  confounded  with  the  heel,  the 
elbow,  or  the  shoulder.  From  the  heel,  it  is  distinguished  by  having 
two  tuberosities  instead  of  one ;  from  the  elbow,  by  the  latter 
having  one  sharp  tuberosity,  with  a  depression  on  each  side,  instead 
of  a  central  depression  and  two  lateral  prominences ;  and  from  the 
shoulder,  by  the  latter  being  more  rounded,  liaving  only  one  promi- 
nence, running  from  which  the  acromion  and  clavicle  can  be  traced. 

Diagnosis  of  the  Foot. — The  foot  may  be  mistaken  for  the  hand. 
This  error  will  be  avoided  by  remembering  that  all  the  toes  are  in 
the  same  line,  and  tnat  the  great  toe  cannot  be  brought  into  apposi- 
tion with  the  others,  as  the  thumb  can  with  the  fingers.  The  inter- 
nal border  of  the  foot  is  much  thicker  than  the  external,  whereas 
the  two  borders  of  the  hand  are  of  the  same  thickness.  Moreover, 
the  foot  is  articular  at  right  angles  to  the  leg,  and  cannot  be  brought 
into  a  line  with  it,  as  the  liand  can  with  the  arm.  Finallv,  the  pro- 
jection of  the  calcaneum  is  characteristic,  and  resembles  nothing  in 
the  hand. 

Mechayiisvt. — ^As  is  the  case  in  other  presentations,  obstetricians 
have  very  variously  subdivided  breech  presentations,  with  the  effect 
of  needlessly  complicating  the  subject.  The  simplest  division,  and 
that  which  will  most  readily  impress  itself  on  the  memorv  of  the 
student,  is  to  describe  the  breech  as  presenting  in  four  positions,  anal- 
ogous to  those  of  the  vertex,  the  sacrum  being  taken  as  representing 
the  occiput,  and  the  positions  being  numbered  according  to  the  part 
of  the  pelvis  to  which  it  points.     Thus  we  have — 

First^  or  left  s  aero -anterior  (corresponding  to  the  first  position  of 
the  vertex).  The  sacrum  of  the  child  points  to  the  left  foramen 
ovale  of  the  mother. 

Second,  or  right  sacro-anterior  (corresponding  to  the  second  vertex 
position).  The  sacrum  of  the  child  points  to  the  right  foramen  ovale 
of  the  mother. 

Third  or  right  sacro-posterior  (corresponding  to  the  third  vertex 
position).  The  sacrum  of  the  child  points  to  the  right  sacro-iliac 
synchondrosis  of  the  mother. 

Fourth  or  left  sacro-posterior  (corresponding  to  the  fourth  vertex 
position).^  The  sacrum  of  the  child  points  to  the  left  sacro-iliac  syn- 
chondrosis of  the  mother. 

Of  these,  as  with  the  corresponding  vertex  positions,  the  first  and 
third  are  the  most  common,  their  comparative  frequency,  no  doubt, 
depending  on  the  same  causes.  The  mechanical  conditions  to  which 
the  presenting  part  is  subjected  are  also  identical,  but  the  alterations 
of  positions  of  the  breech  in  its  progress  are  by  no  means  so  uniform 
as  those  of  the  head,  on  account  of  its  less  perfect  adaptation  to  the 


296 


LABOR. 


pelvic  cavity.  The  meclianisra  of  tlie  delivery  of  the  shoulders  and 
head  in  breech  presentations,  moreover,  is  of  n-iuch  greater  practical 
importance  than  that  of  the  body  in  vertex  presentations,  inasmuch 
as  the  safety  of  the  child  depends  on   its  speedy  and  satisfactory  ac- 


E:g.  105. 


First  or  left  Sacro-cotyloid  Position  of  the  Breech. 

eomplishment.  Bearing  these  facts  in  mind,  it  will  suffice  to  describe 
briefly  the  phenomena  of  delivery  in  the  first  and  third  breech 
positions. 

Position  of  the  Child  at  Brim. — In  the  first  position  the  sacrum  of 
the  child  points  to  the  left  foramen  ovale,  its  back  is  consequently 
placed  to  the  left  side  of  the  uterus  and  anteriorly,  and  its  abdomen 
looks  to  the  right  side  of  the  uterus  and  posteriorly.  The  sulcus 
between  the  buttocks  lies  in  the  right  oblique  diameter  of  the  pelvis, 
while  the  transverse  diameter  of  the  buttocks  lies  in  the  left  oblique 
diameter,  the  left  buttock  being  most  easily  within  reach.  As  in 
vertex  presentations  the  hips  of  the  child  lie  on  the  same  level  at 
the  pelvic  brim,  although  Naegele  describes  the  left  hip  as  placed 
lower  than  the  right. 

Descent. — As  the  ]3ains  act  on  the  body  of  the  child,  the  breech 
is  gradually  forced  through  the  pelvic  cavity,  retaining  the  same 
relations  as  at  the  brim,  its  progress  being  generally  more  slow  than 
that  of  the  head,  until  it  reaches  the  lower  pelvic  strait,  when  the 
same  mechanism  which  produces  rotation  of  the  occiput  comes  to 
operate  upon  it.  The  result  is  a  rotation  of  the  child's  pelvis,  so 
that  its  transverse  diameter  comes  to  lie  approximately  in  the  antero- 
posterior diameter  of  the  outlet,  its  antero-posterior  diameter  corre- 
sponds to  the  transverse  diameter  of  the  mother's  pelvis,  the  left  hip 
lies  behind  the  pubis,  and  the  right  towards  the  sacrum.     This  rota- 


PELVIC    PRESENTATIONS.  297 

tion,  wliicli  is  admitted  by  the  majority  of  obstetricians,  is  altogether 
denied  by  Naegele,  There  can  be  no  doubt,  however,  that  it  does 
generally  take  place,  but  by  no  means  so  constantly  as  the  corre- 
sponding rotation  of  the  vertex  ;  and  it  is  not  uncommon  for  it  to 
be  entirely  absent,  and  for  the  hips  to  be  born  in  the  oblique  diam- 
eter of  the  outlet.  The  body  of  the  child  is  said  frequently  not  to 
follow  the  movement  imparted  to  the  hips,  so  that  there  is  more  or 
less  of  a  twist  in  the  vertebral  column. 

Expulsion  of  the  Hips  and  Body. — The  left  hip  now  becomes  firmly 
fixed  behind  the  pubis,  and  a  movement  of  extension,  analogous  to 
that  of  the  head  in  vertex  presentations,  takes  place.  The  right,  or 
posterior,  hip  revolves  round  the  fixed  one,  gradually  distends  the 
perineum,  and  is  expelled  first,  the  left  hip  rapidly  following.  As 
soon  as  both  hips  are  born,  the  feet  slip  out,  unless  the  legs  are  com- 
pletely extended  upon  the  child's  abdomen.  The  shoulders  soon 
follow,  lying  in 'the  left  oblique  diameter  of  the  pelvis:  The  left 
shoulder  rotates  forwards  behind  the  pubis,  where  it  becomes  fixed, 
the  right  shoulder  sweeping  over  the  perineum,  and  being  born 
first.  The  arms  of  the  child  are  generally  found  placed  upon  its 
thorax,  and  are  born  before  the  shoulders.  Sometimes  they  are  ex- 
tended over  the  child's  head,  thus  causing  considerable  delay,  and 
greatly  increasing  the  risk  to  the  child.  It  is  now  generally  ad- 
mitted that  such  extension  is  most  apt  to  occur  when  traction  has 
been  made  on  the  child's  body  with  the  view  of  hastening  delivery, 
and  that  it  is  rarely  met  with  when  the  expulsion  of  the  body  is  left 
entirely  to  the  natural  powers. 

Delivery  of  the  Head. — AVhen  the  shoulders  are  expelled  the  head 
enters  the  pelvis  in  the  opposite,  or  right  oblique  diameter,  the  face 
looking  to  the  right  sacro-iliac  synchondrosis.     As  the  greater  part 

Fig.  106. 


Passage  of  the  Shoulders  and  Partial  Rotation  of  the  Thorax. 

of  the  child  is  now  expelled,  and  as  the  head  has  entered  the  vagina, 
the  uterus,  having  a  comparatively  small  mass  to  contract  upon| 
must  obviously  act  at  a  mechanical  disadvantage.  Still  the  pressure 
of  the  head  on  the  vagina  is  a  powerful  inciter,  the  accessory  muscles 


298 


LABOR. 


of  parturition  are  brought  into  strong  action,  and  there  is  usually 
quite  sufficient  force  to  insure  expulsion  of  the  head  without  artificial 
aid.  On  account  of  the  great  resistance  to  the  descent  of  the  occiput 
from  its  articulation  with  the  spinal  column,  the  pains  have  the 

Fig,  107. 


Descent  of  the  Head. 


eft'ect  of  forcing  down  the  anterior  portion  of  the  head,  and  this 
insures  the  complete  flexion  of  the  chin  upon  the  sternum.  This  is 
a  great  advantage  from  a  mechanical  point  of  view,  as  it  causes  the 
short  occipito-mental  diameter  of  the  head  to  enter  the  pelvis  in  the 
axis  of  the  uterus  and  the  brim.  If  the  head  should  be  in  a  state 
of  partial  extension — as  sometimes  happens  when  the  pelvis  is  un- 
usually roomy — the  occipital  frontal  diameter  is  placed  in  a  similar 
relation  to  the  brim,  a  position  certainly  less  favorable  to  the  easy 
birth  of  the  head.  As  the  head  descends  it  experiences  a  movement 
of  rotation,  the  occiput  passing  forwards  and  to  the  right,  behind  the 
pubic  arch,  the  face  turning  backwards  into  the  hollow  of  the  sacrum. 
The  body  of  the  child  will  be  observed  to  follow  this  movement,  so 
that  its  back  is  turned  towards  the  mother's  abdomen,  its  anterior 
surface  to  the  perineum.  The  nape  of  the  neck  now  becomes  firmly 
fixed  under  the  arch  of  the  pubis,  the  pains  act  chiefly  on  the  ante- 
rior portion  of  the  head,  and  cause  it  to  sweep  over  the  perineum, 
the  chin  being  first  born,  then  the  mouth  and  forehead,  and  lastly 
the  occiput. 

Sacro-posterior  Positions. — -It  is  needless  to  describe  the  differences 
between  the  mechanism  of  the  second  and  first  positions,  which  the 
student,  who  has  mastered  the  subject  of  vertex  presentations,  will 
readily  understand.  It  is  necessary,  however,  to  say  a  few  words  as 
to  sacro-posterior  positions,  choosing  for  that  purpose  the  third,  which 
is  the  more  common  of  the  two.  This  is  exactly  the  opposite  of  the 
first  position.  The  sacrum  of  the  child  points  to  the  right  sacro- 
iliac synchondrosis,  its  abdomen  looks  forward  and  to  the  left  side 
of  the  mother.  The  transverse  diameter  of  the  child's  pelvis  lies  in 
the  left  oblique  diameter,  the  right  hip  being  anterior.     The  birth  of 


PELVIC    PRESENTATIONS.  299 

the  body  generally  takes  place  exactly  in  the  way  that  has  been 
already  described,  the  right  hip  being  towards  the  pubis. 

As  the  head  descends  into  the  pelvis  the  occiput  most  usually 
rotates  along  its  right  side — the  rotation  having  been  often  already 
partially  effected  when  that  of  the  hips  had  been  made — until  it  comes 
to  rest  behind  the  pubis,  the  face  passing  backwards  along  the  left 
side  of  the  pelvis  into  the  hollow  of  the  sacrum.  This  change  cor- 
responds exactly  to  the  anterior  rotation  of  the  occiput  in  occipito- 
posterior  positions,  and  is  the  natural  and  favorable  termination. 

Sometimes,  forward  rotation  does  not  take  place,  and  the  occiput 
then  turns  backwards  into  the  hollow  of  the  sacrum.  What  then 
generally  occurs  is  that  the  pains  continue,  for  the  reason  already 
mentioned,  to  depress  the  chin  and  produce  strong  flexion  of  the  face 
on  the  sternum  the  occiput  becoming  fixed  on  the  anterior  border 
of  the  perineum.  The  pains  continuing  to  act  chiefly  on  the  anterior 
part  of  the  head,  the  face  is  born  first  behind  the  pubis,  the  occiput 
only  slipping  over  the  perineum  after  the  forehead  has  been  ex- 
pelled. 

Second  Mode  in  loliich  such  Cases  occasionally  End. — A  second  mode 
of  termination  of  such  positions  is  mentioned  in  most  works,  on  the 
authority  of  one  or  two  recorded  cases ;  but  although  mechanically 
possible,  it  is  certainly  an  event  of  extreme  rarity.  The  chin,  in- 
stead of  being  flexed  on  the  sternum,  is  greatly  extended,  so  that 
the  face  of  the  child  looks  upwards  towards  the  pelvic  brim.  The 
chin  then  hitches  over  the  upper  edge  of  the  pubis  and  becomes  fixed 
there,  while  the  force  of  the  uterine  contractions  is  expended  on  the 
posterior  part  of  the  head,  which  descends  through  the  pelvis,  dis- 
tending the  perineum,  and  is  born  first,  the  face  subsequently  fol- 
hjwing. 

Mechanism  of  Feet  Presentation.- — -The  mechanism  of  the  delivery 
of  the  body  and  head  in  cases  in  which  the  feet  originallv  present, 
does  not  differ,  in  any  important  respect,  from  that  which  has  been 
already  described,  and  requires  no  separate  notice. 

Treatment. — From  what  has  been  said  of  the  natural  mechanism, 
it  is  evident  that  one  of  the  most  fruitful  causes  of  difficulty  and 
complication  is  undue  interference  on  the  part  of  the  practitioner. 
It  is,  no  doubt,  tempting  to  use  traction  on  the  partially  born  trunk 
in  the  hope  of  expediting  delivery  ;  but  when  it  is  remembered  that 
this  is  almost  certain  to  produce  extension  of  the  arms  above  the 
head,  and  subsequently  extension  of  the  occiput  on  the  spine,  both 
of  which  seriously  increase  the  difficulty  of  delivery,  the  necessity 
of  leaving  the  case  as  much  as  possible  to  nature  will  be  apparent. 

Having  once,  therefore,  determined  the  existence  of  a  'pelvic  pre- 
sentation, nothing  more  should  be  done  until  the  birth  of  the  breech. 
The  membranes  should  be  even  more  carefully  prevented  from  pre- 
maturely rupturing  than  in  vertex  presentations,  since  they  serve  to 
dilate  the  genital  passages  better  than  the  presenting  part.  Hence 
they  should  be  preserved  intact,  if  possible,  until  they  reach  the  floor 
of  the  pelvis,  instead  of  being  punctured  as  soon  as  the  os  is  fully 


300  LABOR. 

dilated.  The  breech  when  born  should  be  received  and  supported 
in  the  palm  of  the  hand. 

Danger  to  Child. — When  the  body  is  expelled  as  far  as  the  umbili- 
cus, the  dangers  to  the  child  commence :  for  now  the  cord  is  apt  to 
be  pressed  between  the  body  of  the  child  and  the  pelvic  walls.  To 
obviate  this  risk  as  much  as  possible,  a  loop  of  the  cord  should  be 
pulled  down,  and  carried  to  that  part  of  the  pelvis  where  there  is 
most  room,  which  will  generally  be  opposite  one  or  the  other  sacro- 
iliac synchondrosis.  As  long  as  the  cord  is  freely  pulsating  we  may 
be  satisfied  that  the  life  of  the  child  is  not  gravely  imperilled,  al- 
though delay  is  fraught  with  danger,  from  other  sources  which  have 
been  already  indicated.  In  most  cases  the  arms  now  slip  out ;  but 
it  may  happen,  even  without  any  fault  on  the  part  of  the  accoucheur, 
that  they  are  extended  above  the  head,  and  it  is  of  great  importance 
that  Ave  should  be  thoroughly  acquainted  with  the  best  means  of 
liberating  them  from  their  abnormal  position. 

Management  when  the  Arms  are  extended  above  the  Head. — They 
must,  of  course,  never  be  drawn  directly  downwards,  or  the  almost 
certain  result  would  be  fracture  of  the  fragile  bones.  We  should 
endeavor  to  make  the  arm  sweep  over  the  face  and  chest  of  the  child, 
so  that  the  natural  movements  of  its  joints  should  not  be  opposed. 
If  the  shoulders  be  within  easy  reach,  the  finger  of  the  accoucheur 
should  be  slipped  over  that  which  is  posterior — because  there  is 
likely  to  be  more  space  for  this  manoeuvre  towards  the  sacrum — 
and  gently  carried  downwards  towards  the  elbow,  which  is  drawn 
over  the  face,  and  then  onwards,  so  as  to  liberate  the  forearm.  The 
same  manoeuvre  should  then  be  applied  to  the  opposite  arm.  It  may 
be  that  the  shoulders  are  not  easily  reached,  and  then  they  may  be 
depressed  by  altering  the  position  of  the  child's  body.  If  this  be 
carried  well  up  to  the  mother's  abdomen,  the  posterior  shoulder  will 
be  brought  lower  down;  and,  by  reversing  this  procedure  and  carry- 
ing the  body  back  over  the  perineum,  the  anterior  shoulder  may  be 
similarly  depressed.  It  is  only  very  exceptionally,  however,  that 
these  expedients  are  required. 

Birth  of  the  Head. — The  arms  being  extracted,  some  degree  of  ar- 
tificial assistance  is,  at  this  time,  almost  always  required.  If  there 
be  much  delay,  the  child  will  almost  certainly  perish.  Attempts 
have  been  made,  in  cases  in  which  delivery  of  the  head  could  not 
be  rapidly  effected,  to  establish  pulmonary  respiration  by  passing 
one  or  two  fingers  into  the  vagina,  so  as  to  press  it  back  and  admit 
air  to  the  child's  mouth,  or  by  passing  a  catheter  or  tube  into  the 
mouth.  Neither  of  these  expedients  are  reliable,  and  we  should 
rather  seek  to  aid  nature  in  completing  the  birth  of  the  head  as  rap- 
idly as  possible.  The  first  thing  to  do,  supposing  the  face  to  have 
rotated  into  the  cavity  of  the  sacrum,  is  to  carry  the  body  of  the 
child  well  up  towards  the  pubis  and  abdomen  of  the  mother  without 
applying  any  traction,  for  fear  of  interfering  with  the  all-important 
flexion  of  the  chin  on  the  sternum.  If  now  the  patient  bear  down 
strongly,  the  natural  powers  may  be  sufficient  to  complete  delivery. 
If  there  be  any  delay,  traction  must  be  resorted  to,  and  we  must  en- 


PELVIC    PRESENTATIONS.  301 

deavor  to  apply  it  in  sucli  a  way  as  to  insure  flexion.  For  this  pur- 
pose, while  the  body  of  tlie  child  is  grasped  by  the  left  hand,  and 
drawn  upwards  towards  the  mother's  abdomen,  the  index  and  middle 
fingers  of  the  right  hand  are  placed  on  the  back  of  the  child's  neck, 
so  that  their  tips  press  on  either  side  of  the  base  of  the  occiput,  and 
push  the  head  into  a  state  of  flexion.  In  most  works  we  are  advised 
to  pass  the  index  and  middle  fingers  of  the  left  hand  at  the  same 
time  over  the  child's  face,  so  as  to  depress  the  superior  maxilla.  Dr. 
Barnes  insists  that  this  is  quite  unnecessary,  and  that  extraction  in 
the  manner  indicated,  by  pressure  on  the  occiput,  is  quite  sufficient. 
Should  it  not  prove  so,  flexion  of  the  chin  may  be  very  eftectually 
assisted  by  downward  pressure  on  the  forehead  through  the  rectum. 
One  or  two  fingers  of  the  left  hand  can  readily  be  inserted  into  the 
bowel,  and  the  expulsion  of  the  head  is  thus  materially  facilitated. 

Value  of  Pressure  through  the  Abdomen. — By  far  the  most  power- 
ful aid,  however,  in  hastening  delivery  of  the  head,  should  delay 
occur,  is  pressure  from  above.  This  has  been,  strangely  enough, 
almost  altogether  omitted  by  writers  on  the  subject.  It  has  been 
strongly  recommended  by  Professor  Penrose,  and  there  can  be  no 
question  of  its  utility.  Indeed,  as  the  uterus  contracts  tightly  round 
the  head,  uterine  expression  can  be  applied  almost  directly  to  the 
head  itself,  and  without  any  fear  of  deranging  its  proper  relation  to 
the  maternal  passages.  It  is  very  seldom,  indeed,  that  a  judicious 
combination  of  traction  on  the  part  of  the  accoucheur,  with  firm 
pressure  through  the  abdomen  applied  by  an  assistant,  will  fail  in 
effecting  delivery  of  the  head  before  the  delay  has  had  time  to  prove 
injurious  to  the  child. 

Application  of  the  Forceps  to  the  After-coming  Head. — Many  accou- 
cheurs— among  others  Meigs,  and  Rigby — advocate  the  application 
of  the  forceps  when  there  is  delay  in  the  birth  of  the  after-coming 
head.  If  the  delay  be  due  to  want  of  expulsive  force  in  a  pelvis  of 
normal  size,  manual  extraction,  in  the  manner  just  described,  will  be 
found  to  be  sufficient  in  almost  every  case,  and  preferable,  as  being 
more  rapid,  easier  of  execution,  and  safer  to  the  child.  The  forceps 
may  be  quite  properly  tried,  if  other  means  have  failed ;  especially 
if  there  be  some  disproportion  between  the  size  of  the  head  and  the 
pelvis. 

Management  of  Sacro-posterior  Positions. — Difficulties  in  delivery 
may  also  occur  in  sacro-posterior  positions.  Up  to  the  time  of  the 
birth  of  the  head  the  labor  usually  progresses  as  readily  as  in  sacro- 
anterior positions.  If  the  forward  rotation  of  the  hips  do  not  take 
place,  much  subsequent  difficulty  may  be  prevented  by  gently  favor- 
ing it  by  traction  applied  to  the  breech  during  the  pains,  the  finger 
being  passed  for  this  purpose  into  the  fold  of  the  groin. 

It  is  after  the  birth  of  the  shoulders  that  the  absence  of  rotation  is 
most  likely  to  prove  troublesome.  It  has  been  recommended  that 
the  body  should  then  be  grasped,  in  the  interval  between  the  pains, 
and  twisted  round  so  as  to  bring  the  occiput  forward.  It  is  by  no 
means  certain,  however,  that  the  head  would  follow  the  movement 
imparted  to  the  body,  and  there  must  be  a  serious  danger  of  giving 


302  LABOR. 

a  fatal  twist  of  the  neck  by  such  a  manoeuvre.  The  better  plan  is  to 
direct  the  face  backwards,  towards  the  cavity  of  the  sacrum,  by 
pressing  on  the  anterior  temple  during  the  continuance  of  a  pain. 
In  this  way  the  proper  rotation  will  generally  be  effected  without 
much  difficulty,  and  the  case  will  terminate  in  the  usual  way. 

Management  of  Gases  in  which  Forward  Rotation  does  not  occur. — If 
rotation  of  the  occiput  forwards  do  not  occur,  it  is  necessary  for  the 
practitioner  to  bear  in  mind  the  natural  mechanism  of  delivery  under 
such  circumstances.  In  the  majority  of  cases  the  proper  plan  is  to 
favor  flexion  of  the  chin  by  upward  pressure  on  the  occiput,  and  to 
exert  traction  directly  backwards,  remembering  that  the  nape  of  the 
neck  should  be  fixed  against  the  anterior  margin  of  the  perineum. 
If  this  be  not  remembered,  and  traction  be  made  in  the  axis  of  the 
pelvic  outlet,  the  delivery  of  the  head  Avill  be  seriously  impeded.  In 
the  rare  cases  in  which  the  head  becomes  extended,  and  the  chin 
hitches  on  the  upper  margin  of  the  pubis,  traction  directl}'-  forwards 
and  upwards  may  be  required  to  deliver  the  head;  but  before  resort- 
ing to  it  care  should  be  taken  to  ascertain  that  backward  extension 
of  the  head  has  really  taken  place. 

Management  of  Im.pacted  Breech  Presentations. — It  remains  for  us 
to  consider  the  measures  which  may  be  adopted  in  those  very 
troublesome  cases  in  which  the  breech  refuses  to  descend,  and  be- 
comes impacted  in  the  pelvic  cavity,  either  from  uterine  inertia,  or 
from  disproportion  between  the  breech  and  the  pelvis.  Here,  un- 
fortunately, the  peculiar  shape  of  the  presenting  part,  which  is  un- 
adapted  for  the  application  of  the  forceps,  renders  such  cases  very 
difficult  to  manage. 

Two  measures  have  been  chiefly  employed :  1st,  bringing  down 
one  or  both  feet,  so  as  to  break  up  the  presenting  part,  and  convert 
it  into  a  footling  case ;  2d,  traction  on  the  breach,  either  by  the 
fingers,  a  blunt  hook,  or  fillet  passed  over  the  groin. 

Barnes  insists  on  the  superiority  of  the  former  plan,  and  there  can 
be  no  question  that,  if  a  foot  can  be  got  down,  the  accoucheur  has  a 
complete  control  over  the  progress  of  the  labor,  which  he  can  gain 
in  no  other  way.  If  the  breech  be  arrested  at  or  near  the  brim,  there 
Avill  generally  be  no  great  difficulty  in  effecting  the  desired  object. 
It  will  be  necessary  to  give  chloroform  to  the  extent  of  complete 
anaesthesia,  and  to  pass  the  hand  over  the  child's  abdomen  in  the 
same  manner,  and  with  the  same  precautions,  as  in  performing  podalic 
version,  until  a  foot  is  reached,  which  is  seized  and  pulled  down.  If 
the  feet  be  placed  in  the  usual  way  close  to  the  buttocks,  no  great 
difficulty  is  likely  to  be  experienced.  If,  however,  the  legs  be  ex- 
tended on  the  abdomen,  it  will  be  necessary  to  introduce  the  hand 
and  arm  very  deeply,  even  up  to  the  fundus  of  the  uterus,  a  proced- 
ure which  is  always  difficult,  and  which  may  be  very  hazardous. 
Nor  do  I  think  that  the  attempt  to  bring  down  tlie  feet  can  be  safe 
when  the  breech  is  low  down  and  fixed  in  the  pelvic  cavity.  A 
certain  amount  of  repression  of  the  breech  is  possible,  but  it  is 
evident  that  this  cannot  be  safely  attempted  when  the  breech  is  at 
all  low  down. 


PRESENTATIONS    OF    THE    FACE.  303 

Traction  on  the  Groin. — Under  sucli  circumstances  traction  is  our 
only  resource,  and  tins  is  always  difficult  and  often  unsatisfactory. 
Of  all  contrivances  for  tliis  purpose  none  is  better  tlian  the  band  of 
the  accoucheur.  The  index  finger  can  generally  be  slipped  over  the 
groin  without  difficulty,  and  traction  can  be  applied  during  the 
pains,  Failing  this,  or  when  it  proves  insufficient,  an  attempt  should 
be  made  to  pass  a  fillet  over  the  groins.  A  soft  silk  handkerchief, 
or  a  skein  of  worsted,  answers  best,  but  it  is  by  no  means  easy  to 
apply.  The  simplest  plan,  and  one  which  is  far  better  than  the  ex- 
pensive instruments  contrived  for  the  purpose,  is  to  take  a  stout 
piece  of  copper  wire  and  bend  it  double  into  the  form  of  a  hook. 
The  extremity  of  this  can  generally  be  guided  over  the  hips,  and 
through  its  looped  end  the  fillet  is  passed.  The  wire  is  now  Avith- 
drawn,  and  carries  the  fillet  over  the  groins.  I  have  found  this 
simple  contrivance,  which  can  be  manufactured  in  a  few  moments, 
very  useful,  and  by  means  of  such  a  fillet  very  considerable  tractive 
force  can  be  employed.  The  use  of  a  soft  fillet  is  in  every  way  pref- 
erable to  the  blunt  hook  which  is  contained  in  most  obstetric  bags. 
A  hard  instrument  of  this  kind  is  quite  as  difficult  to  apply,  and  any 
strong  traction  employed  by  it  is  almost  certain  to  seriously  injure 
the  delicate  foetal  structures  over  which  it  is  placed.  As  an  auxiliary 
the  employment  of  uterine  expression  should  not  be  forgotten,  since 
it  may  give  material  aid  when  the  difficulty  is  only  due  to  uterine 
inertia.  After  a  difficult  breech  labor  is  completed  the  child  should 
be  carefully  examined  to  see  that  the  bones  of  the  thighs  and  arms 
have  not  been  injured.  Fractures  of  the  thigh  are  far  from  uncom- 
mon in  such  cases,  and  the  soft  bones  of  the  newly  born  child  will 
readily  and  rapidly  unite  if  placed  at  once  in  proper  splints. 

Embryotomy. — Failing  all  endeavors  to  deliver  by  these  expedients, 
there  is  no  resource  left  but  to  break  up  the  presenting  part  by  scis- 
sors, or  by  craniotomy  instruments ;  but  fortunately  so  extreme  a 
measure  is  but  rarely  necessary. 


CHAPTER    VI. 

PEESENTATIONS    OF    THE    FACE. 

Presentations  of  the  face  are  by  no  means  rare ;  and,  although 
in  the  great  majority  of  cases  they  terminate  satisfactorily  by  the 
unassisted  powers  of  nature,  yet  every  now  and  again  they  give  rise 
to  much  difficulty,  and  then  they  may  be  justly  said  to  be  amongst 
the  most  formidable  of  obstetric  complications.  It  is,  therefore, 
essential    that   the  practitioner   should  thoroughly  understand  the 


304  LABOR. 

natural  liistorj  of  this  variety  of  presentation,  witli  tlie  view  of 
enabling  him  to  intervene  with  the  best  prospect  of  success. 

Erroneous  Views  formerly  held  on  the  Subject. — The  older  accou- 
cheurs held  very  erroneous  views  as  to  the  mechanism  and  treatment 
of  these  cases,  most  of  them  believing  that  delivery  was  impossible 
by  the  natural  eftbrts,  and  that  it  was  necessary  to  intervene  by 
version  in  order  to  effect  delivery,  Smellie  recognized  the  fact  that 
spontaneous  delivery  is  possible,  and  that  the  chin  turns  forwards 
and  under  the  pubis ;  but  it  was  not  until  long  after  his  time,  and 
chiefly  after  the  appearance  of  Mme.  La  Chapelle's  essay  on  the 
subject,  that  the  fact  that  most  cases  could  be  naturally  delivered 
was  fully  admitted  and  acted  upon. 

Frequency. — The  frequency  of  face  presentations  varies  curiously  in 
different  countries.  Thus,  Collins  found  that  in  the  Rotunda  Hos- 
pital there  was  only  1  case  in  497  labors,  although  Churchill  gives 
1  in  249  as  the  average  frequency  in  British  practice ;  while  in  Ger- 
many this  presentation  is  met  with  once  in  169  labors.  The  only 
reasonable  explanation  of  this  remarkable  difference  is,  that  the 
dorsal  decubitus,  generally  followed  abroad,  favors  the  transforma- 
tion of  vertex  presentations  into  those  of  the  face. 

The  mode  in  which  this  change  is  effected — for  it  can  hardly  be 
doubted  that,  in  the  large  majority  of  cases,  face  presentation  is  due 
to  a  backward  displacement  of  the  occiput  after  labor  has  actually 
commenced,  but  before  the  head  has  engaged  in  the  brim — has  been 
made  the  subject  of  various  explanations. 

Mode  in  which  Face  Presentations  are  produced. — It  has  generally 
been  supposed  that  the  change  is  induced  by  a  hitching  of  the 
occiput  on  the  brim  of  the  pelvis,  so  as  to  produce  extension  of 
the  head,  and  descent  of  the  face ;  the  occurrence  being  favored  by 
the  oblique  position  of  the  uteriis  so  frequently  met  with  in  preg- 
nancy. Hecker  attaches  considerable  importance  to  a  peculiarity 
in  the  shape  of  the  foetal  head  generally  observed  in  face  presenta- 
tions, the  cranium  having  the  dolicho-cephalous  form,  prominent 
posteriorly,  with  occiput  projecting,  which  has  the  effect  of  increas- 
ing the  length  of  the  posterior  cranial  lever  arm,  and  facilitating 
extension  when  circumstances  favoring  it  are  in  action.  Dr.  Dun- 
can^ thinks  that  uterine  obliquity  has  much  influence  in  the  produc- 
tion of  face  presentation,  but  in  a  different  way  from  that  above 
referred  to.  He  points  out  that,  when  obliquity  is  very  marked,  a 
curve  in  the  genital  passages  is  produced,  the  convexity  of  which  is 
directed  to  the  side  towards  which  the  uterus  is  deflected.  When 
uterine  contraction  commences,  the  foetus  is  propelled  downwards, 
and  the  cavity  of  the  curve  is  acted  on  to  the  greatest  advantage 
by  the  propelling  force,  and  tends  to  descend.  Should  the  occiput 
happen  to  lie  in  the  convexity  of  the  curve  so  formed,  the  tendency 
will  be  for  the  forehead  to  descend.  In  the  majority  of  cases  its 
descent  will  be  prevented  by  the  increased  resistance  it  meets  with, 
in  consequence  of  the  greater  length  of  the  anterior  cranial  lever 

'  Edin.  Med.  Jour.,  vol.  xy. 


PRESENTATIONS    OF    THE    FACE.  305 

arm  ;  but  if  the  uterine  obliquity  be  extreme,  this  may  be  co-unter- 
balanced,  and  a  face  presentation  ensues.  The  influence  of  this 
obliquity  is  corroborated  by  the  observation  of  Baudelocque,  that 
the  occiput  in  face  presentations  almost  invariably  corresponds  to 
the  side  of  the  uterine  obliquity.  A  further  corroboration  is  afi'orded 
by  the  fact,  that  in  face  presentation  the  occiput  is  much  more  fre- 
quently directed  to  the  right  than  to  the  left ;  while  right  lateral 
obliquity  of  the  uterus  is  also  much  more  common. 

These  theories  assume  that  face  presentations  are  produced  during 
labor.  In  a  few  cases  they  certainly  exist  before  labor  has  com- 
menced. It  is  possible,  however,  as  we  know  that  uterine  contrac- 
tions exist  independently  of  actual  labor,  that  similar  causes  may 
also  be  in  operation,  although  less  distinctly,  before  the  commence- 
ment of  labor. 

Diagnosis. — The  diagnosis  is  often  a  matter  of  considerable  diffi- 
culty at  an  early  period  of  labor,  before  the  os  is  fully  dilated  and 
the  membranes  ruptured,  and  when  the  face  has  not  entered  the 
pelvic  cavity.  The  finger  then  impinges  on  the  rounded  mass  of  the 
forehead,  which  may  very  readily  be  mistaken  for  the  vertex.  At 
this  stage  the  diagnosis  may  be  facilitated  by  abdominal  palpation 
in  the  way  suggested  by  Hecker.  If  the  face  is  presenting  at  the 
brim,  palpation  will  enable  us  to  distinguish  a  hard,  firm,  and 
rounded  body,  immediately  above  the  pubis,  which  is  the  forehead 
and  sinciput ;  on  the  other  side  will  be  felt  an  indistinct  soft  sub- 
stance, corresponding  to  the  thorax  and  neck.  When  labor  is  ad- 
vanced, and  the  head  has  somewhat  descended,  or  when  the 
membranes  are  ruptured,  we  should  be  able  to  make  out  the  nature 
of  the  presentation  with  certainty.  The  diagnostic  marks  to  be 
relied  on  are  the  edges  of  the  orbits,  the  prominence  of  the  nose,  the 
nostrils  (their  orifices  showing  to  which  part  of  the  pelvis  the  chin 
is  turned),  and  the  cavity  of  the  mouth,  with  the  alveolar  ridges. 
If  these  be  made  out  satisfactorily,  no  mistake  should  occur.  The 
most  difficult  cases  are  those  in  which  the  face  has  been  a  consider- 
able time  in  the  pelvis.  Under  such  circumstances  the  cheeks  be- 
come greatly  swollen  and  pressed  together,  so  as  to  resemble  the 
nates.  The  nose  might  then  be  mistaken  for  the  genital  organs,  and 
the  mouth  for  the  anus.  The  orbits,  however,  and  the  alveolar 
ridges,  resemble  nothing  in  the  breech,  and  should  be  sufficient  to 
prevent  error.  Considerable  care  should  be  taken  not  to  examine 
too  frequently  and  roughly,  otherwise  serious  injury  to  the  delicate 
structures  of  the  face  might  be  inflicted.  When  once  the  presenta- 
tion has  been  satisfactorily  diagnosed,  examinations  should  be  made 
as  seldom  as  possible,  and  only  to  assure  ourselves  that  the  case  is 
progressing  satisfactorily. 

Mechanism.— li  we  regard  face  presentations,  as  we  are  fully  justi- 
fied in  doing,  as  being  generally  produced  by  the  extension  of  the 
occiput  in  what  were  originally  vetex  presentations,  we  can  readily 
understand  that  the  position  of  the  face  in  relation  to  the  pelvis  must 
correspond  to  that  of  the  vertex.     This  is,  in  fact,  what  is  found  to 


306  LABOR, 

be  the  case,  tlie  forehead  occupying  the  position  in  which  the  occiput 
would  have  been  placed  had  extension  not  occurred. 

The  Positions  of  the  Face  correspond  to  those  of  the  Vertex.- — -The 
face,  then,  like  the  head,  may  be  placed  with  its  long  diameter 
corresponding  to  almost  any  of  the  diameters  of  the  brim,  but  most 
generally  it  lies  either  in  the  transverse  diameter,  or  between  this 
and  the  oblique,  while,  as  it  descends  m  the  pelvis,  it  more  generally 
occupies  one  or  other  of  the  oblique  diameters.  It  is  common  in 
obstetric  works  to  describe  two  principal  varieties  of  face  presenta- 
tion, viz.,  the  right  and  left  mento-iliac,  according  as  the  chin  is 
turned  to  one  or  other  side  of  the  pelvis.  It  is  better,  however,  to 
classify  the  positions  in  accordance  with  the  part  of  the  pelvis  to 
which  the  chin  points.  We  may,  therefore,  describe  four  positions 
of  the  face,  each  being  analogous  to  one  of  the  ordinary  vertex 
presentations,  of  which  it  is  the  transformation. 

First  position. — The  chin  points  to  the  right  sacro-iliac  synchon- 
drosis, the  forehead  to  the  left  foramen  ovale,  and  the  long  diameter 
of  the  face  lies  in  the  right  oblique  diameter  of  the  pelvis.  This- 
corresponds  to  the  first  position  of  the  vertex,  and,  as  in  that,  the 
back  of  the  child  lies  to  the  left  side  of  the  mother. 

Second  position. — The  chin  points  to  the  left  sacro-iliac  synchon- 
drosis, the  forehead  to  the  right  foramen  ovale,  and  the  long  diameter 

Fig.  108. 


Second  Position  in  Face  Presentations. 


of  the  face  lies  in  the  left  oblique   diameter  of  the  pelvis.     This  is 
the  conversion  of  the  second  vertex  position. 

Third  position. — The  forehead  points  to  the  right  sacro-iliac  syn- 
chondrosis, the  chin  to  the  left  foramen  ovale,  and  the  long  diameter 


PRESENTATIONS    OF    THE    FACE.  307 

of  the  face  lies  m  the  right  oblique  diameter  of  the  pelvis.     This  is 
the  conversion  of  the  third  vertex,  position. 

Fotirtli  position. — The  forehead  points  to  the  left  sacro-iliac  sjm- 
chondrosis,  the  chin  to  the  right  foramen  ovale,  and  tlie  long  diam- 
eter of  the  face  lies  in  the  left  oblique  diameter  of  the  pelvis.  This 
is  the  conversion  of  the  fourth  vertex  position. 

Relative  Frequency  of  these  Positions. — The  relative  frequency  of 
these  presentations  is  not  yet  positively  ascertained.  It  is  certain 
that  tliere  is  not  the  preponderance  of  first  facial  that  there  is  of  first 
vertex  positions,  and  this  may,  no  doubt,  be  explained  by  the  suppo- 
sition that  an  unusual  vertex  position  may  of  itself  facilitate  the 
transformation  into  a  face  presentation.  Winckel  concludes  that, 
cseteris  paribus.^  a  face  presentation  is  more  readily  produced  when 
the  back  of  the  child  lies  to  the  right  than  when  it  lies  to  the  left 
side  of  the  mother;  the  reason  for  this  being  probably  the  frequency 
of  right  lateral  obliquity  of  the  uterus.  We  shall  presently  see  that, 
with  very  rare  exceptions,  it  is  absolutely  essential  that  the  chin 
should  rotate  forwards  under  the  pubis  before  delivery  can  be 
accomplished ;  and,  therefore,  we  may  regard  the  third  and  fourth 
face  positions,  in  which  the  chin  from  the  first  points  anteriorly,  as 
more  favorable  than  the  first  and  second. 

Mechanism. — The  inechanism  of  delivery  in  face  is  practically  the 
same  as  in  vertex  presentations;  and  we  shall  have  no  difficulty  in 
understanding  it  if  we  bear  in  mind  that  in  face  cases  the  forehead 
takes  the  place,  and  represents  the  occiput  in  vertex  presentations. 
For  the  purpose  of  description  we  will  take  the  first  position  of  the 
face — 

Description  of  Delivery  in  the  First  Position  of  the  Face. — 1.  The 
first  step  consists  in  the  extension  of  the  head,  which  is  effected  by 
the  uterine  contractions  as  soon  as  the  membranes  are  ruptured.  By 
this  the  occiput  is  still  more  completely  pressed  back  on  the  nape  of 
the  neck,  and  the  fronto-mental,  rather  than  the  mento-bregmatic, 
diameter  is  placed  in  relation  to  the  pelvic  brim.  This  corresponds 
to  the  stage  of  flexion  in  vertex  presentations. 

The  chin  descends  below  the  forehead,  from  precisely  the  same 
cause  as  the  occiput  in  vertex  presentations.  On  account  of  the  ex- 
tended position  of  the  head  the  presenting  face  is  divided  into  por- 
tions of  unequal  length  in  relation  to  the  vertebral  column,  through 
which  the  force  is  applied,  the  longer  lever  arm  being  towards  the 
forehead.  The  resistance  is,  therefore,  greatest  towards  the  fore- 
head, which  remains  behind  while  the  chin  descends. 

2,  Descent. — As  the  pains  continue,  the  head  (the  chin  being  still 
in  advance)  is  propelled  through  the  pelvis.  It  is  generally  said  that 
the  face  cannot  descend,  like  the  occiput,  down  to  the  floor  of  the 
pelvis,  its  descent  being  limited  by  the  length  of  the  neck.  There  is 
here,  however,  an  obvious  misapprehension.  The  neck,  from  the 
chin  to  the  sternum,  when  the  head  is  forcibly  extended,  measures 
from  3|  to  4  inches,  a  length  that  is  more  than* sufficient  to  admit  of 
the  face  descending  to  the  lower  pelvic  strait.  As  a  matter  of  fact 
the  chin  is  frequently  observed  in  mento-posterior  positions  to  de- 


308 


LABOR. 


scend  so  far  tliat  it  is  apparently  endeavoring  to  pass  the  perineum 
before  rotation  occurs.  At  the  brim  the  two  sides  of  the  face  are  on 
a  level,  but  as  labor  advances,  the  right  cheek  descends  somewhat, 
the  caput  succedaneum  forms  on  the  malar  bone,  and,  if  a  secondary 
caput  succedaneum  form,  on  the  cheek. 

3.  Rotation  is  by  far  the  most  important  point  in  the  mechanism 
of  face  presentations;  for  unless  it  occurs,  delivery,  with  a  full-sized 
head  and  an  average  pelvis,  is  practically  impossible.  There  are,  no 
doubt,  exceptions  to  this  rule,  which  must  be  separately  considered, 
but  it  is  certain  that  the  absence  of  rotation  is  always  a  grave  and 
formidable  complication  of  face  presentation.  Fortunately  it  is  only 
very  rarely  that  it  is  not  effected.  The  mechanical  causes  are  pre- 
cisely those  which  produce  rotation  of  the  occiput  forwards  in  vertex 
presentations.  As  it  is  accomplished,  the  chin  passes  under  the  arch 
of  the  pubis,  and  the  occiput  rotates  into  the  hollow  of  the  sacrum 
(Fig.  109);  and  then  commences — 

Fig.  109. 


Eotatioa  Forwards  of  CMn. 


4.  Flexion^  a  movement  which  corresponds  to  extension  in  vertex 
cases.  The  chin  passes  as  far  as  it  can  under  the  pubic  arch,  and 
there  becomes  fixed.  The  uterine  force  is  now  expended  on  the  oc- 
ciput which  revolves,  as  it  were,  on  its  transverse  axis  (Fig.  110), 
the  under  surface  of  the  chin  resting  on  the  pubis  as  a  fixed  point. 
This  movement  goes  on  until,  at  last,  the  face  and  occiput  sweep  over 
the  distended  perineum. 

5.  External  Rotation  is  precisely  similar  to  that  which  takes  place 
in  head  presentations,  and,  like  it,  depends  on  the  movements  im- 
parted to  the  shoulders. 

Such  is  the  natural    course  of  delivery  in  the  vast  majority  of 


PRESENTATIONS    OF    THE    FACE. 


309 


cases  ;  but,  in  order  fully  to  understand  the  subject,  it  is  necessary 
to  study  those  rare  cases  in  which  the  cliin  points  backwards,  and 


Fig.  110. 


Passage  of  the  Head  througli  the  Kxterual  Parts  in  Face  Presentation. 

forward  rotation  does  not  occur.     These  may  be  taken  to  correspond 
to  the  occipito-posterior  positions,  in  which  the  face  is  born  looking 

Fig.  111. 


lUustratiug  the  Position  of  the  Head  when  Foi-ward  Rotation  of  the  Chin 
does  not  take  place. 

to  the  pubes ;  but  unlike  them,  it  is  only  very  exceptionally  that 
delivery  can  be  naturally  completed.  The  reason  of  this  is  obvious, 
for  the  occiput  gets  jammed  behind  the  pubis,  and  there  is  no  space 


310  LABOR. 

for  tlie  fronto-mental  diameter  to  pass  the  antero-posterior  diameter 
of  the  outlet  (Fig.  111).  Oases  are  indeed  recorded,  in  which  delivery 
has  been  effected  with  the  chin  looking  posteriorly  ;  but  there  is  every 
reason  to  believe  that  this  can  only  happen  when  the  head  is  either 
unusually  small,  or  the  pelvis  unusually  large.  In  such  cases  the 
forehead  is  pressed  down  until  a  portion  appears  at  the  ostium  vagi- 
nae, when  it  becomes  firmly  fixed  behind  the  pubis,  and  the  chin, 
after  many  efforts,  slips  over  the  perineum.  When  this  is  effected, 
flexion  occurs,  and  the  occiput  is  expelled  without  difficulty.  The 
forehead  is  probably  always  on  a  lower  level  than  the  chin. 

Dr.  Hicks^  has  published  a  paper,  in  which  he  attempts  to  show 
that  this  termination  of  face  presentations  is  not  so  rare  as  is  gene- 
rally supposed,  and  he  gives  a  single  instance  in  which  he  effected 
delivery  with  the  forceps ;  but  he  practically  admits  that  special 
conditions  are  necessary,  such  as  the  "  antero-posterior  diameter  of 
the  outlet  particularly  ample,"  and  a  diminished  size  of  the  head. 
When  delivery  is  effected  it  is  probable,  as  Cazeaux  has  pointed  out, 
that  the  face  lies  in  the  oblique  diameter  of  the  outlet,  and  that  the 
chin  depresses  the  soft  structures  at  the  side  of  the  sacro-ischiatic 
notch,  which  yield  to  the  extent  of  a  quarter  of  an  inch  or  more, 
and  thereby  permit  the  passage  of  the  occipito-mental  diameter  of 
the  head.  It  must,  however,  be  borne  well  in  mind,  that  spontane- 
ous delivery  in  mento-posterior  positions  is  the  rare  exception,  and 
that  supposing  rotation  does  not  occur — and  it  often  does  so  at  the 
last  moment — artificial  aid  in  one  form  or  another  will  be  almost 
certainly  required. 

Prognosis  of  Face  Presentations. — As  regards  the  mother,  in  the 
great  majority  of  cases  the  prognosis  is  favorable,  but  the  labor  is 
apt  to  be  prolonged,  and  she  is,  therefore,  more  exposed  to  the  risks 
attending  tedious  delivery.  As  regards  the  child,  the  prognosis  is 
much  more  unfavorable  than  in  vertex  presentations.  Even  when 
the  anterior  rotation  of  the  chin  takes  place  in  the  natural  way,  it  is 
estimated  that  1  out  of  10  children  is  stillborn ;  while  if  not,  the 
death  of  the  child  is  almost  certain.  This  increased  infantile  mor- 
tality is  evidently  due  to  the  serious  amount  of  pressure  to  which 
the  child  is  subjected,  and  probably  depends  in  many  cases  on  cere 
bral  congestion,  produced  by  pressure  on  the  jugular  veins,  as  the 
neck  lies  in  the  pelvic  cavity.  Even  when  the  child  is  born  alive, 
the  face  is  always  greatly  swollen  and  disfigured.  In  some  cases  the 
deformity  produced  in  this  way  is  excessive,  and  the  features  are 
often  scarcely  recognizable,  this  disfiguration  passes  away  in  a 
few  days ;  but  the  p'ractitioner  should  be  aware  of  the  probability  of 
its  occurrence,  and  should  warn  the  friends,  or  they  might  be  unne- 
cessarily alarmed,  and  ])ossibly  might  lay  the  blame  on  him. 

Treatment. — After  what  has  been  said  as  to  the  mechanism  of  de- 
livery in  face  presentation,  it  is  obvious  that  the  proper  course  is  to 
leave  the  case  alone,  in  the  expectation  of  the  natural  efforts  being 

1  Obst.  Trans.,  vol.  vii. 


PRESENTATIONS    OF    THE    FACE.  311 

sufficient  to  complete  delivery.  Fortunately,  in  the  large  majority 
of  cases,  this  course  is  attended  by  a  successful  result. 

The  older  accoucheurs,  as  has  been  stated,  thought  active  inter- 
ference absolutely  essential,  and  recommended  either  podalic  version, 
or  the  attempt  to  convert  the  case  into  a  vertex  presentation,  by  in- 
serting the  hand  and  bringing  down  the  occiput.  The  latter  plan 
was  recommended  by  Baudelocque,  and  is  even  yet  followed  by  some 
accoucheurs.  Thus  Dr.  Hodge'  advises  it  in  all  cases  in  wdiich  face 
presentation  is  detected  at  the  brim  ;  but  although  it  might  not  have 
been  attended  with  evil  consequences  in  his  experienced  hands,  it  is 
certainly  altogether  unnecessary,  and  would  infallibly  lead  to  most 
serious  results  if  generally  adojjted.  It  may,  however,  be  allowable 
in  certain  cases  in  which  the  face  remains  above  the  brim,  and  re- 
fuses to  descend  into  the  pelvic  cavity.  Even  then  it  is  questionable 
whether  podalic  version  should  not  be  preferred,  as  being  easier  of 
performance,  giving,  when  once  effected,  a  much  more  complete  con- 
trol over  delivery,  and  being  less  painful  to  the  mother.  Version  is 
certainly  preferable  to  the  application  of  the  forceps,  which  are  in- 
troduced with  difficulty  in  so  high  a  position  of  the  face,  and  do  nob 
take  a  secure  hold. 

When  once  the  face  has  descended  into  the  pelvis,  difficulties  may 
arise  from  two  chief  causes;  uterine  inertia,  and  non-rotation  for- 
wards of  the  chin. 

The  treatment  of  the  former  class  must  be  based  on  precisely  the 
same  general  principles  as  in  dealing  with  protracted  labor  in  vertex 
presentations.  The  forceps  may  be  applied  with  advantage,  bearing 
in  mind  the  necessity  of  getting  the  chin  under  the  pubis,  and,  when 
this  has  been  effected,  of  directing  the  traction  forwards,  so  as  to 
make  the  occiput  slowly  and  gradually  distend  and  sweep  over  the 
perineum. 

Difficulties  arising  from  Non-rotation  of  Chin  Forwards.  —  The 
second  class  of  difficult  face  cases  are  much  more  important,  and  may 
try  the  resources  of  the  accoucheur  to  the  utmost.  Our  first  en- 
deavor must  be,  if  possible,  to  secure  the  anterior  rotation  of  the  chin. 
For  this  purpose  various  manoeuvres  are  recommended.  By  some, 
we  are  advised  to  introduce  the  finger  cautiously  into  the  mouth  of 
the  child,  and  draw  the  chin  forwards  during  a  pain ;  by  others,  to 
pass  the  finger  up  behind  the  occiput  and  press  it  backAvards  during 
the  pain.  Schroeder  points  out  that  the  difficult}^  often  depends  on 
the  fact  of  the  head  not  being  sufficiently  extended,  so  that  the  chin 
is  not  on  a  lower  level  than  the  forehead ;  and  that  rotation  is  best 
promoted  by  pressing  the  forehead  upwards  with  the  finger  during 
a  pain,  so  as  to  cause  the  chin  to  descend.  Penrose^  believes  that 
non-rotation  is  generally  caused  by  the  want  of  a  point  cVappui  be- 
low, on  account  of  the  face  being  able  to  descend  to  the  floor  of  the 
pelvis,  and  that,  if  this  is  supplied,  rotation  will  take  place.  In 
such  cases  he  applies  the  hand,  or  the  blade  of  the  forceps,  so  as  to 

■  System  of  Obstetrics,  p.  335. 

2  Amer.  Supplement  to  Obst.  Journ.,  April,  1876. 


312  LABOR.      ■ 

press  on  the  posterior  cheek.  Bj  this  means  the  necessary  "  point 
d'appui"  is  given ;  and  he  relates  several  interesting  cases  in  which 
this  simple  manoeuvre  was  efi'ectual  in  rapidly  termiaating  a  pre- 
viously lengthy  labor.  Any,  or  all,  of  these  plans  may  be  tried. 
We  must  bear  in  mind,  in  using  them,  that  rotation  is  often  delayed 
until  the  face  is  quite  at  the  lower  pelvic  strait,  so  that  we  need  not 
too  soon  despair  of  its  occurring.  If,  however,  in  spite  of  these 
manoeuvres,  it  do  not  take  place,  what  is  to  be  done  ?  If  the  head 
be  not  too  low  down  in  the  pelvis  to  admit  of  version,  that  would  be 
the  simplest  and  most  effectual  plan.  I  have  succeeded  in  delivering 
in  this  way,  when  all  attempts  at  producing  rotation  had  failed ;  but 
generally  the  face  will  be  too  decidedly  engaged  to  render  it  possible. 
An  attempt  might  be  made  to  bring  dovv^n  the  occiput  by  the  vectis, 
or  by  a  fi-llet ;  but  if  the  face  be  in  the  pelvic  cavity,  it  is  hardly 
possible  for  this  plan  to  succeed.  An  endeavor  may  be  made  to  pro- 
duce rotation  by  the  forceps;  but  it  should  be  remembered  that  rota- 
tion of  the  face  mechanically  in  this  way  is  very  difficult,  and  much 
more  likely  to  be  attended  with  fatal  consequences  to  the  child,  than 
when  it  is  effected  by  the  natural  efforts.  In  using  forceps  for  this 
purpose,  the  second  or  pelvic  curve  is  likely  to  prove  injurious,  and 
a  short  straight  instrument  is  to  be  preferred.  If  rotation  be  found 
to  be  impossible,  an  endeavor  may  be  made  to  draw  the  face  down- 
wards, so  as  to  get  the  chin  over  the  perineum,  and  deliver  in  the 
mento-posterior  position  ;  but,  unless  fhe  child  be  small,  or  the  pelvis 
very  capacious,  the  attempt  is  unlikely  to  succeed.  Finally,  if  all 
these  means  fail,  there  is  no  resource  left  but  lessening  the  size  of 
the  head  by  craniotomy,  a  dernier  ressort  which,  fortunately,  is  very 
rarely  required. 

Brow  Presentations. — It  sometimes  happens  that  the  head  is  par- 
tially extended,  so  as  to  bring  the  os  frontis  into  the  brim  of  the  pelvis, 
and  form  what  is  described  as  a  "  hroiu  presentation.''''  Should  the 
head  descend  in  this  manner,  the  difficulties,  although  not  insupera- 
ble, are  apt  to  be  very  great,  from  the  fact  that  the  long  cervico- 
frontal  diameter  of  the  head  is  engaged  in  the  pelvic  cavity.  The 
diagnosis  is  not  difficult,  for  the  os  frontis  will  be  detected  by  its 
rounded  surface;  while  the  anterior  fontanelle  is  within  reach  in 
one  direction,  the  orbit,  and  root  of  the  nose,  in  another. 

Spontaneously  converted  into  either  Face  or  Yertex  Presentations. — 
Fortunately,  in  the  large  majority  of  cases  brow  presentations  are 
spontaneously  converted  into  either  vertex  or  face  presentations, 
according  as  flexion  or  extension  of  the  head  occurs;  and  these  must 
be  regarded  as  the  desirable  terminations  and  the  ones  to  be  favored. 
For  this  purpose  upward  pressure  must  be  made  on  one  or  other  ex- 
tremity of  the  presenting  part  during  a  pain,  so  as  to  favor  flexion, 
or  extension ;  or,  if  the  parts  be  sufficiently  dilated,  an  attempt  may 
be  made  to  pass  the  hand  over  the  occiput  and  draw  it  down,  thus 
performing  cephalic  version:  The  latter  is  the  plan  recommended 
by  Hodge,  who  describes  the  operation  as  easy.  It  is  questionable> 
however,  if  a  well-marked  brow  presentation  be  distinctly  made  out 
while  the  head  is  still  at  the  brim,  whether  podalic  version  would 


DIFFICULT    OCCIPITO-POSTERIOR    POSITIONS.  613 

not  be  the  easiest  and  best  operation.  If  the  forehead  have  descended 
too  low  for  this,  and  if  the  endeavor  to  convert  it  into  either  a  face 
or  vertex  presentation  fail,  the  forceps  will,  probably,  be  required. 
In  such  cases  the  face  generally  turns  towards  the  pubes,  the  supe- 
rior maxilla  becomes  hxed  behind  the  pubic  arch,  and  the  occiput 
sweeps  over  the  perineum.  Very  great  difficulty  is  likely  to  be  ex- 
perienced, and  if  conversion  into  either  a  vertex  or  face  presentation 
cannot  be  effected,  craniotomy  is  not  unlikely  to  be  required. 


CHAPTER    VII. 

DIFFICULT  OCCIPITO-POSTERIOR  POSITIONS. 

A  FEW  words  may  be  said  in  this  place  as  to  the  management  of 
occipito-posterior  positions  of  the  head,  especially  of  those  in  which 
forward  rotation  of  the  occiput  does  not  take  place.  It  has  already 
been  pointed  out  that,  in  the  large  majority  of  these  cases,  the  occiput 
rotates  forward  without  any  particular  difficulty,  and  the  labor  termi- 
nates in  the  usual  way,  with  the  occiput  emerging  under  the  arch  of 
the  pubis. 

Rotation  Forwards  of  the  Occiput. — In  a  certain  number  of  cases 
such  rotation  does  not  occur,  and  difficulty  and  delay  are  apt  to  fol- 
low. The  proportion  of  cases  in  Avhich  face  to  pubis  terminations  of 
occipito-posterior  positions  occurs  has  been  variously  estimated,  and 
they  are  certainly  more  common  than  most  of  our  text-books  lead 
us  to  expect.  Dr.  Uvedale  West,'  who  studied  the  subject  with  great 
care,  found  that  labor  ended  in  this  way  in  79  out  of  2585  births,  all 
these  deliveries  being  exceptionally  difficult. 

Causes  of  Face  to  Pubis  Delivery.- — ^He  believed  that  forward  rota- 
tion of  the  head  is  prevented  by  the  absence  of  flexion  of  the  chin 
on  the  sternum,  so  that  the  long  occipito-frontal,  instead  of  the  short 
sub-occipito-bregmatic,  diameter  of  the  head  is  brought  into  contact 
with  the  pelvic  diameter ;  hence  the  occiput  is  no  longer  the  lowest 
point,  and  is  not  subjected  to  the  action  of  those  causes  which  pro- 
duce forward  rotation.  Dr.  Macdonald,  who  has  written  a  thoughtful 
paper  on  the  subject,^  believes  that  the  non-rotation  forward  of  the 
occiput  is  chiefly  due  to  the  large  size  of  the  head,  in  consequence 
of  which  "the  forehead  gets  so  wedged  into  the  pelvis  anteriorly 
that  its  tendency  to  slacken  and  rotate  forward  does  not  come  into 
play."  Dr.  West's  explanation,  which  has  an  important  bearing  on 
the  management  of  these  cases,  seems  to  explain  most  correctly  the 
non-occurrence  of  the  natural  rotation. 

'  Cranial  Presentations,  p.  33.  2  Edin.  Med.  Jour.,  Oct.  1874. 

21 


314  LABOR. 

The  important  question  for  us  to  decide  is,  how  can  we  best  assist 
in  the  management  of  cases  of  this  kind  when  difficulties  arise,  and 
labor  is  seriously  retarded  ? 

Mode  of  Treatment.- — Dr.  West,  insisting  strongly  on  the  necessity 
of  complete  flexion  of  the  chin  on  the  sternum,  advises  that  this 
should  be  favored  by  upward  pressure  on  the  frontal  bone,  with  the 
view  of  causing  the  chin  to  approach  the  sternum,  and  the  occiput 
to  descend,  and  thus  to  come  within  the  action  of  the  agencies  which 
favor  rotation.  Supposing  the  pains  to  be  strong,  and  the  fontanelle 
to  be  readily  within  reach,  we  may,  in  this  way,  very  possibly  favor 
the  descent  of  the  occiput;  and  without  injuring  the  mother,  or  in- 
creasing the  difficulties  of  the  case  in  the  event  of  the  manoeuvre 
failing.  The  beneficial  effects  of  this  simple  expedient  are  some- 
times very  remarkable.  In  two  cases  in  which  I  recently  adopted 
it,  labor,  previously  delayed  for  a  length  of  time  without  any  appa- 
rent progress,  although  the  pains  were  strong  and  effective,  was  in 
each  instance  rapidly  finished  almost  immediately  after  the  upward 
pressure  was  applied.  The  rotation  of  the  face  backwards  may  at 
the  same  time  be  favored  by  pressure  on  the  pubic  side  of  the  fore- 
head during  the  pains. 

Traction  on  the  Occiput. — Others  have  advised  that  the  descent  of 
the  occiput  should  be  promoted  by  downward  traction,  applied  by  the 
vectis  or  fillet.  The  latter  is  the  plan  specially  advocated  by  Hodge  ;^ 
and  the  fillet  certainly  finds  one  of  its  most  useful  applications  in 
cases  of  this  kind,  as  being  simpler  of  application,  and  probably 
more  effective,  than  the  vectis. 

Over-active  Endeavors  at  Assistance  should  he  avoided. — Although 
any  of  these  methods  may  be  adopted,  a  word  of  caution  is  necessary 
against  prolonged  and  over-active  endeavors  at  producing  flexion  and 
rotation  when  that  seems  delayed.  All  who  have  watched  such  cases 
must  have  observed  that  rotation  often  occurs  spontaneously  at  a  very 
advanced  period  of  labor,  long  after  the  head  has  been  pressed  down 
for  a  considerable  time  to  the  very  outlet  of  the  pelvis,  and'  when  it 
seems  to  have  been  makinsr  fruitless  endeavors  to  emerge;  so  that  a 
little  patience  will  often  be  sufficient  to  overcome  the  difficulty. 

[  Version  hj  the  Vertex. — In  order  to  adapt  this  section  to  American 
practice,  I  addressed  letters  of  inquiry  upon  the  management  of 
occipito-posterior  positions  to  several  obstetrical  professors  and 
teachers,  and  have  prepared  this  article  accordingly. 

1.  ^^  In  pri7nitive  oblique  occipito-posterior  positions  of  the  head, 
nature  will  almost,  without  exception,  cause  spontaneous  rotation  of 
the  occiput  to  the  symphysis  pubis;  but  to  favor  this  movement  the 
bag  of  waters  should  be  preserved." 

2.  "  Spontaneous  rotation,  as  a  rule,  does  not  begin  until  the  head 
meets  with  resistance  from  the  floor  of  the  pelvis ;  hence  no  effort 
to  force  rotation  should  be  made  until  nature  has  proved  herself 
inadequate." 

3.  Where  rotation  forward  is  prevented,  it  is  probabl}^  due  to  the 

'  System  of  Obstetrics,  p.  308, 


DIFFICULT    OCCIPITO-POSTERIOR    POSITIONS.  315 

position  of  the  occiput  Laving  been  originally  directly  backward, 
and  only  becoming  oblique  after  the  descent  of  the  head  into  the 
pelvis,  the  position  of  the  child's  body  preventing  the  anterior  move- 
ment of  its  occiput.  That  is,  the  sixth  position  of  Hodge  has  changed 
into  a  fourth  or  fifth,  but  will  not  without  assistance  become  a  tirst 
or  second. 

4.  If,  then,  rotation  is  not  spontaneous  after  the  head  reaches  the 
floor  of  the  pelvis,  version  by  the  vertex  will  not  take  place  except 
it  be  forced  by  the  vectis  or  forceps. 

One  professor  writes,  "I  have  thus  far  succeeded  so  well"  {i.  e.,  by 
the  vectis  and  forceps),  "that  I  recall  but  one  instance  in  which  the 
head  was  born  with  the  occiput  looking  to  the  sacrum."  Another 
says  he  applies  the  forceps  and  lets  "  the  progress  of  the  head  deter- 
terraine  the  mode  by  which  it  shall  make  its  exit ;  not  trying  to 
turn  by  the  forceps." 

In  the  primitive  occipito-sacral  jMsitioyi  changed  to  ohlique^  or  in  the 
more  rare  unchanged  sixth  position  of  Hodge,  if  the  head  is  large  or 
the  pelvis  in  any  way  obstructed,  the  case  may  require  to  be  termi- 
nated by  craniotomy.  It  is  even  possible  to  rotate  the  occiput  from 
the  sacrum  to  the  pubes  and  save  the  child,  as  this  was  once  done 
by  the  late  Dr.  William  Harris,  of  Philadelphia.  Of  course,  the  body 
must  have  partly  rotated. 

Use  of  the  Hand  in  Occvpito -posterior  Positions. — The  introduction 
of  the  hand  for  the  purpose  of  effecting  version  by  the  vertex,  under 
an  ansesthetic,  was  strongly  advocated  by  the  late  Dr.  John  S.  Parry,* 
of  Philadelphia,  who  certainly  used  his  own,  which  was  small  and 
thin,  to  very  great  advantage.  Several  very  small-handed  accoucheurs 
in  this  city  have  found  their  hands  of  yqtj  great  value  in  some  cases 
of  obstetrics  ;  and  it  is  said  that  a  celebrated  Neapolitan  obstetrician 
owes  his  great  popularity  to  the  advantage  thus  derived.  It  will 
not  do  to  advocate  a  general  use  of  the  hand  in  obstetric  practice, 
as  few  have  such  as  it  would  be  safe  to  use,  especially  in  primiparee. 
I  have  known  a  primipara  labor  for  hours  to  deliver  herself  of  a 
foetus  in  an  occipito-posterior  position,  when  all  that  was  needed  was 
the  assistance  of  a  suitable  hand  during  three  pains  to  bring  the 
occiput  fairly  under  the  arch  of  the  pubis. — Ed.] 

When  necessary  the  Forceps  'may  he  Used. — In  the  event  of  assist- 
ance being  absolutely  required,  there  is  no  reason  why  the  forceps 
should  not  be  used.  The  instrument  is  not  more  difficult  to  apply 
than  under  ordinary  circumstances,  nor,  as  a  rule,  is  much  more  trac- 
tion necessary.  Dr.  Macdonald,  indeed,  in  the  paper  already  alluded 
to,  maintains  that  m  persistent  occipito-posterior  positions  there  is 
almost  always  a  want  of  proportion  between  the  head  and  the  pelvis, 
and  that,  therefore,  the  forceps  will  be  generally  required,  and  he 
prefers  them  to  any  artificial  attempts  at  rectification.  Some  pecu- 
liarities in  the  mode  of  delivery  are  necessary  to  bear  in  mind.  In 
most  works  it  is  taught,  that  the  operator  should  pay  special  atten- 
tion to  the  rotation  of  the  head,  and  should  endeavor  to  impart  this 

['  Am.  Jour.  0])stetrics,  May,  1875.] 


31B  LABOR. 

movement  by  turning  the  occiput  forward  during  extraction.  Thus 
Tyler  Smith  says,  "In  delivery  with  the  forceps  in  occipito- posterior 
presentations,  the  head  should  be  slowly  rotated  during  the  process 
of  extraction  so  as  to  bring  the  vertex  towards  the  pubic  arch,  and 
thus  convert  them  into  occipito-anterior  presentations."  The  danger 
accompanying  any  forcible  attempt  at  artificial  rotation  will,  how- 
ever, be  evident  on  slight  consideration.  It  is  true  that  in  many 
cases,  when  simple  traction  is  a;:plied,  the  occiput  will,  of  itself,  ro- 
tate forwards,  carrying  the  instrument  with  it.  But  that  is  a  very 
different  thing  from  forcibly  twisting  round  the  head  with  the  blades 
of  the  forceps,  without  any  assurance  that  the  body  of  the  child  will 
follow  the  movement.  It  is  impossible  to  conceive  that  such  violent 
interference  should  not  be  attended  with  serious  risk  of  injury  to  the 
neck  of  the  child.  If  rotation  do  not  occur,  the  fair  inference  is, 
that  the  head  is  so  placed  as  to  render  delivery  with  the  face  to  the 
pubis  the  best  termination,  and  no  endeavor  should  be  made  to  pre- 
vent it.  This  rule  of  leaving  the  rotation  entirely  to  nature,  and 
using  traction  only,  has  received  the  approval  of  Barnes  and  most 
modern  authorities,  and  is  the  one  Avhich  recommends  itself  as  the 
most  scientific  and  reasonable. 

Objection  to  Curved  histrumenis  in  such  Cases. — These  are  cases  in 
which  the  pelvic  curve  of  the  forceps  is  of  doubtful  utility.  Wheti 
applied  in  the  usual  way  the  convexity  of  the  blades  points  back- 
wards. If  rotation  accompany  extraction,  the  blades  necessarily 
follow  the  movement  of  the  head,  and  their  convex  edges  will  turn 
forwards.  It  certainly  seems  probable  that  such  a  movement  would 
subject  the  maternal  soft  parts  to  considerable  risk.  I  have  how- 
ever, more  than  once  seen  such  rotation  of  the  instrument  happen 
without  any  apparent  bad  result ;  but  the  dangers  are  obvious. 
Hence  it  would  be  a  wise  precaution,  either  to  use  a  pair  of  straight 
forceps  for  this  particular  operation,  or  to  remove  the  blades  and 
leave  the  case  to  be  terminated  by  the  natural  powers,  when  the  head 
is  at  the  lower  strait,  and  rotation  seems  about  to  occur.  When 
there  is  no  rotation,  more  than  usual  care  should  be  taken  with  the 
perineum,  which  is  necessarily  much  stretched  by  the  rounded  occiput. 
Indeed  the  risk  to  the  perineum  is  very  considerable,  and,  even  with 
the  greatest  care,  it  may  be  impossible  to  avoid  laceration. 

'Bearing  these  precautions  in  mind,  delivery  with  the  forceps  in 
occipito-posterior  positions  offers  no  special  difficulties  or  dangers. 


PRESENTATIONS  OF  SHOULDER,  ETC.  317 


CHAPTER  VIIL 

PRESENTATIONS   OF  THE   SHOULDER,    ARM,    OR   TRUNK — COMPLEX 
PKESENTATIONS— PROLAPSE  OF  THE  FUNIS. 

In  the  presentations  already  considered  the  long  diameter  of  the 
foetus  corresponded  with  that  of  the  uterine  cavity,  and,  in  all  of 
them,  the  birth  of  the  child  by  the  maternal  efforts  was  the  general 
and  normal  termination  of  labor.  We  have  now  to  discuss  those 
important  cases  in  which  the  long  diameter  of  the  foetus  and  uterus 
do  not  correspond,  but  in  which  the  long  foetal  diameter  lies  ob- 
liquely across  the  uterine  cavity.  In  the  large  majority  of  these  it  is 
either  the  shoulder,  or  some  part  of  the  upper  extremity,  that  presents; 
for  it  is  an  admitted  fact  that  although  other  parts  of  the  body,  such 
as  the  back,  or  abdomen,  may,  in  exceptional  cases,  lie  over  the  os 
at  an  early  period  of  labor,  yet,  as  labor  progresses,  such  presenta- 
tions are  almost  always  converted  into  those  of  the  upper  extremity. 

For  all  practical  purposes  we  may  confine  ourselves  to  a  considera- 
tion of  shoulder  presentations;  the  further  subdivision  of  these  into 
elbow  or  hand  presentations  being  no  more  necessary  than  the  division 
of  pelvic  presentations  into  breech,  knee,  and  footling  cases,  since 
the  mechanism  and  management  are  identical,  whatever  part  of  the 
upper  extremity  presents. 

Delivery  hy  the  Natural  Poivers  is  quite  Exceptional. — There  is  this 
great  distinction  between  the  presentations  we  are  now  considering 
and  those  already  treated  of,  that,  on  account  of  the  relations  of  the 
foetus  to  the  pelvis,  delivery  by  the  natural  powers  is  imjiossible, 
except  under  special  and  very  unusual  circumstances  that  can  never 
be  relied  upon.  Intervention  on  the  part  of  the  accoucheur  is,  there- 
fore, absolutely  essential,  and  the  safety  of  both  the  mother  and 
child  depends  upon  the  early  detection  of  the  abnormal  position  of 
the  foetus ;  for  the  necessary  treatment,  which  is  comparatively  easy 
and  safe  before  labor  has  been  long  in  progress,  becomes  most  difl&- 
Gult  and  "hazardous  if  there  have  been  much  delay. 

Position  of  the  Fodtns. — -Presentations  of  the  upper  extremity  or 
trunk  are  often  spoken  of  as  '■'transverse  presentations'^  or  '■'■cross 
births  ;^^  but  both  of  these  terms  are  misleading,  as  they  imply  that 
the  foetus  is  placed  transversely  in  the  uterine  cavity,  or  that  'it  lies 
directly  across  the  pelvic  brim.  As  matter  of  fact,  this  is  never  the 
case,  for  the  child  lies  obliquely  in  the  uterus,  not  indeed  in  its 
long  axis,  but  in  one  intermediate  between  its  long  and  transverse 
diameters. 

Divided  into  Dorso-cmterior  and  Dorso-posterior  Positions. — Two 
great  divisitms  of  shoulder  presentations  are  recognized;  the  one  in 
which  the  back  of  the  child  looks  to  the  abdomen  of  the  mother 


318  LABOR. 

(Fig.  112),  and  the  other  in  which  the  back  of  the  child  is  turned 
towards  the  spiue  of  the  mother  (Fig.  113).     Bach  of  these  is  sub- 

FiG.  112. 


Dorso-anterior  Presentation  of  the  Arm. 


divided  into  two  subsidiary  classes,  according  as  the  head  of  the 
child  is  placed  iu  the  right  or  left  iliac  fossa.    Thus  in  dorso-anterior 


Fig.  113. 


Dorso- posterior  Presentation  of  the  Arm. 


positions,  if  the  head  lie  in  the  left  iliac  fossa,  the  right  shoulder  of 
the  child  presents ;  if  in  the  right  iliac  fossa,  the  left.  So  in  dorso- 
posterior  positions,  if  the  head  lie  in  the  left  iliac  fossa,  the  left 


PRESENTATIONS  OF  SHOULDER,  ETC.  319 

shoulder  present;  if  in  the  right,  the  right.  Of  the  two  classes  the 
dorso-anterior  positions  are  more  conunon,  in  the  proportion,  it  is 
said,  of  two  to  one. 

Causes. — The  causes  of  shoulder  presentation  are  not  well  known. 
Amono-st  those  most  commonly  mentioned  are  prematuritj"  of  the 
foetus,  and  excess  of  liquor  ainnii ;  either  of  these,  by  increasing  the 
mobility  of  the  foetus  in  utero,  would  probably  have  considerable 
influence.  The  fact  that  it  occurs  much  more  frequently  amongst 
premature  births  has  long  been  recognized.  Undue  obliquity  of  the 
uterus  has  probably  some  influence,  since  the  early  pains  might 
cause  the  presenting  part,  to  hitch  against  the  pelvic  brim,  and  the 
shoulder  to  descend.  An  ■unusually  low  attachment  of  the  placenta 
to  the  inferior  segment  of  tlie  uterine  cavity  has  been  mentioned  as 
a  predisposing  cause.  In  consequence  of  this  the  head  does  not  lie 
so  readily  in  the  lower  uterine  segment,  and  is  apt  to  slip  up  into 
one  of  the  iliac  fossae.  This  is  supposed  to  explain  the  frequency  of 
arm  presentation  in  cases  of  partial  or  complete  placenta  pra3via. 
Danyou  and  Wigand  believe  that  shoulder  presentations  are  favored 
by  irregularity  in  the  shape  of  the  uterine  cavity,  especially  a  rela- 
tive increase  in  its  transverse  diameter.  This  theory  has  been  gene- 
rally discredited  by  writers,  and  it  is  certainly  not  susceptible  of 
proof;  but  it  seems  far  from  unlikely  that  some  peculiarity  of  shape 
may  exist,  not  capable  of  recognition,  but  sufficient  to  influence  the 
position  of  the  foetus.  How  otherwise  are  we  to  explain  those  remark- 
able cases,  many  of  which  are  recorded,  in  which  similar  malpositions 
occurred  in  many  successive  labors?  Thus  Joulin  refers  to  a  patient 
who  had  an  arm  presentation  in  three  successive  pregnancies,  and  to 
another  who  had  shoulder  presentation  in  three  out  of  four  labors. 
Certainly,  such  constant  recurrences  of  the  same  abnormality  could 
only  be  explained  on  the  hypothesis  of  some  very  persistent  cause, 
such  as  that  referred  to.  Pinard^  states  that  shoulder  presentations 
are  seven  times  more  common  in  multiparte  than  in  primiparce,  in 
consequence,  as  he  believes,  of  the  laxity  of  the  abdominal  walls  in 
the  former,  which  allows  the  uterus  to  fall  forwards,  and  thus  prevents 
the  head  entering  the  pelvic  brim  in  the  latter  weeks  of  pregnancy. 
It  is  probable  that  merely  accidental  causes  have  most  influence  in 
the  production  of  shoulder  presentation,  such  as  falls,  or  undue  pres- 
sure exerted  on  the  abdomen  by  badly  fitting  or  tight  sta_ys.  Partial]}?" 
transverse  positions  during  pregnancy  are  certainly  much  more  com- 
mon than  is  generally  believed,  and  may  often  be  detected  by  abdominal 
palpation.  The  tendency  is  for  such  malpositions  to  be  righted  either 
before  labor  sets  in,  or  in  the  early  period  of  labor  ;  but  it  is  quite  easy 
to  understand  how  any  persistent  pressure,  applied  in  the  manner  in- 
dicated, may  perpetuate  a  position  which  otherwise  would  have  been 
only  temporary. 

Prognosis  and  Frequency. — According  to  Churchill's  statistics, 
shoulder  presentations  occur  about  once  in  260  cases,  that  is  only 
slightly  less  frequently  than  those  of  the   face.     The  prognosis  to 

'  Annal.  d'hyg.  pub.  et  de  med.,  Jan.  1879. 


320  LABOR. 

both,  the  mother  and  child  is  much  more  unfavorable  ;  for  he  esti- 
mates that  out  of  235  cases  1  in  9  of  the  mothers,  and  half  the  chil- 
dren were  lost.  The  prognosis  in  each  individual  case  will,  of  course, 
vary  much  with  the  period  of  delivery  at  wliich  the  malposition  is 
recognized.  If  detected  early,  interference  is  easy,  and  the  prognosis 
ought  to  be  good ;  whereas  there  are  few  obstetric  difficulties  more 
trying  than  a  case  of  shoulder  presentation,  in  which  the  necessary 
treatment  has  been  delayed  until  the  presenting  part  has  been  tightly 
jammed  into  the  cavity  of  the  pelvis. 

Diagnosis. — Bearing  this  fact  in  mind,  the  paramount  necessity  of 
an  accurate  diagnosis  will  be  apparent;  and  it  is  specially  important 
that  we  should  be  able  not  only  to  detect  that  a  shoulder  or  arm  is 
presenting,  but  that  we  should,  if  possible,  determine  which  it  is,  and 
how  the  body  and  head  of  the  child  are  placed.  The  existence  of  a 
shoulder  presentation  is  not  generally  suspected,  until  the  first  vaginal 
examination  is  made  during  labor.  The  practitioner  will  then  be 
struck  with  the  absence  of  the  rounded  mass  of  the  foetal  head,  and, 
if  the  OS  be  open  and  the  membranes  protruding,  by  their  elongated 
form,  which  is  common  to  this  and  to  other  malpresentations.  If 
the  presenting  part  be  too  high  to  reach,  as  is  often  the  case  at  an 
early  period  of  labor,  an  endeavor  should  at  once  be  made  to  ascer- 
tain the  foetal  position  by  abdominal  examination.  This  is  the  more 
important,  as  it  is  much  more  easy  to  recognize  presentations  of  the 
shoulder  in  this  way  than  those  of  the  breech  or  foot;  and,  at  so 
early  a  period,  it  is  often  not  only  possible,  but  comparatively  easy, 
to  alter  the  position  of  the  foetus  by  abdominal  manipulation  alone, 
and  thus  avoid  the  necessity  of  the  more  serious  form  of  version. 
The  method  of  detecting  a  shoulder  presentation  by  examination  of 
the  abdomen  has  already  been  described  (p.  116),  and  need  not  be 
repeated.  The  chief  points  to  look  for  are,  the  altered  shape  of  the 
uterus,  and  two  solid  masses,  the  head  and  the  breech,  one  in  either 
iliac  fossa.  The  facility  with  which  these  parts  may  be  recognized 
varies  much  in  different  patients.  In  thin  women,  with  lax  abdomi- 
nal parietes,  they  can  be  easily  felt ;  while  in  very  stout  women,  it 
may  be  impossible.  Failing  this  method,  we  must  rely  on  vaginal 
examinations  ;  although,  before  the  membranes  are  ruptured,  and 
when  the  presenting  part  is  high  in  the  pelvis,  it  is  not  always  easy 
to  gain  accurate  information  in  this  way.  The  difficulty  is  increased 
by  the  paramount  importance  of  retaining  the  membranes  intact  as 
long  as  possible.  It  should  be  remembered,  therefore,  that  when  a 
presentation  of  the  superior  extremity  is  suspected,  the  necessary 
examinations  should  only  be  made  in  the  intervals  between  the  pains 
when  the  membranes  are  lax,  and  never  when  they  are  rendered 
tense  by  the  uterine  contractions. 

As  either  the  shoulder,  the  elbow,  or  the  hand,  may  present,  it 
will  be  best  to  describe  the  peculiarities  of  each  separately,  and  the 
means  of  distinguishing  to  which  side  of  the  body  the  presenting 
part  belongs. 

1.  The  shoulder  is  recognized  as  a  ronnd  smooth  prominence,  at 
one  point  of  which  may  often  be  felt  the  sharp  edge  of  the  acromion. 


PRESENTATIONS  OP  SHOULDER.  ETC.  321 

If  the  finger  can  be  passed  sufficiently  liigh,  it  may  be  possible  to  feel 
the  clavicle,  and  the  spine  of  the  scapula.  A  still  more  complete 
.  examination  may  enable  us  to  detect  the  ribs  and  the  intercostal 
spaces,  which  would  be  quite  conclusive  as  to  the  nature  of  the 
presentation,  since  there  is  nothing  resembling  them  in  any  other 
part  of  the  body.  At  the  side  of  the  shoulder,  the  hollow  of  the 
axilla  may  generally  be  made  out. 

Mode  of  D'uujnoslwj  the  Posiilon  of  the  Child. — In  order  to  ascer- 
tain the  position  of  the  child  we  have  to  find  out  in  which  iliac  fossa 
the  head  lies.  This  may  be  done  in  two  ways  :  1st.  The  head  may 
be  felt  through  the  abdominal  parietes  by  palpation ;  and  2d,  since 
the  axilla  always  points  towards  the  feet,  if  it  point  to  the  left  side 
the  head  must  lie  in  the  right  iliac  fossa,  if  to  the  right,  the  head 
must  be  placed  in.  the  left  iliac  fossa.  Again,  the  spine  of  the  scapula 
must  correspond  to  the  back  of  the  child,  the  clavicle  to  its  abdomen; 
and,  by  feeling  one  or  other,  we  know  whether  we  have  to  do  with 
a  dorso-anterior  or  dorso- posterior  position.  If  we  cannot  satisfac- 
torily determine  the  position  by  these  means,  it  is  quite  legitimate 
practice  to  bring  down  the  arm  carefully,  provided  the  membranes 
are  ruptured,  so  as  to  examine  the  hand,  which  will  be  easily  recog- 
nized as  right  or  left.  This  expedient  will  decide  the  point ;  but  it 
is  one  which  it  is  better  to  avoid,  if  possible,  for  it  not  only  slightly 
increases  the  difficulty  of  turning,  although  perhaps  not  very  mate- 
rially, but  the  arm  might  possibly  be  injured  in  the  endeavor  to  bring 
it  down. 

Differential  Diafjnosis  of  the  Shoulder. — The  only  part  of  the  body 
likely  to  be  taken  for  the  shoulder  is  the  breech ;  but  in  that  its 
larger  size,  the  groove  in  which  the  genital  organs  lie,  the  second 
prominence  formed  by  the  other  buttock,  and  the  sacral  spinous 
processes  are  sufficient  to  prevent  a  mistake. 

2.  The  elhoio  is  rarely  felt  at  the  os,  and  may  be  readily  recognized 
by  the  sharp  prominence  of  the  olecranon,  situated  between  tAvo  lesser 
prominences,  the  condyles.  As  the  elbow  always  points  towards  the 
feet,  the  position  of  the  foetus  can  be  easily  ascertained. 

3.  The  liand  is  easy  to  recognize,  and  can  only  be  confounded  with 
the  foot.  It  can  be  distino-uished  by  its  borders  beino-  of  the  same 
thickness,  by  the  fingers  being  wider  apart  and  more  readily  sepa- 
rated from  each  other  than  the  toes,  and  above  all  by  the  mobility 
of  the  thumb,  which  can  be  carried  across  the  palm,  and  placed  in 
apposition  with  each  of  the  fingers. 

Mode  of  Detecting  which  Hand  is  Presentimf. — It  is  not  difficult  to 
tell  which  hand  is  presenting.  If  the  hand  be  in  the  vagina,  or 
beyond  the  vulva,  and  within  easy  reach,  we  recognize  which  it  is  by 
laying  hold  of  it  as  if  we  were  about  to  shake  hands.  If  the  palm 
lie  in  the  palm  of  the  practitioner's  hand,  with  the  two  thumbs  in 
apposition,  it  is  the  right  hand;  if  the  back  of  the  hand,  it  is  the  left. 
Another  simple  way  is,  for  the  practitioner  to  imagine  his  own  hand 
placed  in  precisely  the  same  position  as  that  of  the  foetus ;  and  this 
will  readily  enable  him  to  verify  the  previous  diagnosis.  A  simple 
rule  tells  us  how  the  body  of  the  child  is  placed,  for,  provided  we 


322  LABOR. 

are  sure  the  liand  is  in  a  state  of  supination,  the  back  of  the  hand 
points  to  the  back  of  the  child,  the  pahn  to  its  abdomen,  the  thumb 
to  tlie  head,  and  tlie  bttle  finger  to  tlie  feet. 

Mechanism. — It  is  perhaps  liardly  proper  to  talk  of  a  mechanism 
of  shoulder  presentations,  since,  if  left  unassisted,  they  almost  inva- 
riably lead  to  the  gravest  consequences.  Still,  nature  is  not  entirely 
at  fault  even  here,  and  it  is  well  to  study  the  means  she  adopts  to 
terminate  these  malpositions. 

Terminations. — There  are  two  pos-sible  terminations  of  shoulder 
presentation.  In  one,  known  as  ^''spontaneous  version^''''  some  other 
part  of  the  foetus  is  substituted  for  that  originally  presenting ;  in 
the  other,  '■'■  spontaneoas  evolution^''''  the  foetus  is  expelled  by  being 
squeezed  through  the  pelvis,  without  the  originally  presenting  part 
being  withdrawn.  It  cannot  be  too  strongly  impressed  on  the  mind 
that  neither  of  these  can  be  relied  on  in  practice. 

Spontaneous  version  may  occasionally  occur  before,  or  immediately 
after,  the  rupture  of  the  membranes,  when  the  foetus  is  still  readily 
movable  within  the  cavity  of  the  uterus.  A  few  authenticated 
cases  are  recorded  in  which  the  same  fortunate  issue  took  place  after 
the  shoulder  had  been  engaged  in  the  pelvic  brim  for  a  considerable 
time,  or  even  after  prolapse  of  the  arm  ;  but  its  probability  is  neces- 
sarily much  lessened  under  sucli  circumstances.  Either  the  head  or 
the  breech  may  be  brought  down  to  the  os  in  place  of  the  original 
presentation. 

The  precise  mechanism  of  spontaneous  version,  or  the  favoring 
circumstances,  are  not  sufficientl}^  understood  to  justify  any  positive 
statement  with  regard  to  it. 

Cazeaux  believed  that  it  is  produced  b}^  partial  or  irregular  con- 
traction of  the  uterus,  one  side  contracting  energetically,  while  the 
other  remains  inert,  or  only  contracts  to  a  slight  degree.  To  illus- 
trate how  this  may  effect  spontaneous  version,  let  us  suppose  that 
the  child  is  lying  with  the  head  in  the  left  iliac  fossa.  Then  if  the 
left  side  of  the  uterus  should  contract  more  forcibly  than  the  right, 
it  would  clearly  tend  to  push  the  head  and  shoulder  to  the  right  side, 
until  the  head  came  to  present  instead  of  the  shoulder.  A  very  in- 
teresting case  is  related  by  Geneuil,^  in  which  he  was  present  during 
spontaneous  version,  in  the  course  of  which  the  breech  was  substi- 
tuted for  the  left  shoulder  more  than  four  hours  after  the  rupture  of 
the  membranes.  In  this  case  the  uterus  was  so  tightly  contracted 
that  version  was  impossible.  He  observed  the  side  of  the  uterus 
opposite  the  head  contracting  energetically,  the  other  remaining  flac 
cid,  and  eventually  the  case  ended  without  assistance,  the  breech  pre- 
senting. The  natural  moulding  action  of  the  uterus,  and  the  greater 
tendency  of  the  long  axis  of  the  child  to  lie  in  that  of  the  uterus,  no 
doubt  assist  the  transformation,  and  much  must  depend  on  the  mo- 
bility of  the  foetus  in  any  individual  case. 

That  such  changes  often  take  place  in  the  latter  weeks  of  preg- 
nancy, and  before  labor  has  actually  commenced,  is  quite  certain  and 

'  Ann.  de  Gynecologie,  v.  v.  1876. 


PRESENTATIONS    OF    SHOULDER,    ETC, 


323 


tliev  are  probably  mucli  more  frequent  than  is  generally  supposed. 
When  spontaneous  version  does  occur,  it  is,  of  course,  a  most  favor- 
able event;  and  the  termination  and  prognosis  of  the  labor  are  then 
the  same  as  if  the  head  or  breech  had  originally  presented. 

Spontaneoiis  Evolution. — Tlie  mechanism  of  spontaneous  evolution, 
since  it  was  first  clearly  worked  out  by  Douglas,  has  been  so  often 
and  carefully  described,  that  we  know  precisely  how  it  occurs.  Al- 
though every  now  and  then  a  case  is  recorded  in  which  a  living 
child  has  been  born  by  this  means,  such  an  event  is  of  extreme 
rarity  ;  and  there  is  no  doubt  of  the  accuracy  of  the  general  opinion, 
that  spontaneous  evolution  can  only  happen  when  the  pelvis  is  un- 
usually roomy  and  the  child  small;  and  that  it  almost  necessarily 
involves  the  death  of  the  foetus,  on  account  of  the  immense  pressure 
to  which  it  is  subjected. 

Two  varieties  are  described,  in  one  of  which  the  head  is  first  born, 
in  the  other  the  breech;  in  both  the  originally  presenting  arm  re- 
mained prolapsed.  The  former  is  of  extreme  rarity,  and  is  believed 
only  to  have  happened  with  very  premature  children,  whose  bodies 
were  small  and  flexible,  and  when  traction  had  been  made  on  the 
presenting  arm.  Under  such  circumstances  it  can  hardly  be  called  a 
natural  process,  and  we  may  confine  our  attention  to  the  latter  and 
more  common  variety. 

What  takes  place  is  as  follows  :  The  presenting  arm  and  shoulder 
are  tightly  jammed  down,  as  far  as  is  possible,  by  the  uterine  con- 
tractions, and  the  head  becomes  strongly  flexed  on  the  shoulder.    As 


Fig.  114. 


^^^ 


Commenciag  Spontaneous  Evolution. 


much  of  the  body  of  the  foetus  as  the  pelvis  will  contain  becomes 
engaged,  and  then  a  movement  of  rotation  occurs,  which  brings  the 
bodv  of  the  child  nearly  into  the  antero-posterior  diameter  of  the 
pelvis  (Fig.  114).  The  shoulder  projects  under  the  arch  of  the 
pubis,  the  head  lying  above  the  symphysis,  and  the  breech  near  the 


324 


LABOR. 


sacro-iliac  synchondrosis.  It  is  essential  that  the  head  should  lie 
forwards  above  the  pubes,  so  that  the  length  of  the  neck  may  per- 
mit the  shoulder  to  project  under  the  pubic  arch,  without  any  part 
of  the  head  entering  the  pelvic  cavity.  The  shoulder  and  neck  of 
the  child  now  become  fixed  points,  round  which  the  body  of  the 
child  rotates,  and  the  whole  force  of  the  uterine  contractions  is  ex- 
pended on  the  breech.  The  latter,  with  the  body,  therefore,  becomes 
more  and  more  depressed,  until,  at  last,  the  side  of  the  thorax  reaches 
the  vulva,  and,  followed  by  the  breech  and  inferior  extremities,  is 
slowly  pushed  out  (Fig.  115).  As  soon  as  the  limbs  are  born  the 
head  is  easily  expelled. 


Fig.  115. 


Spontaneous  Evolution  further  advanced. 

The  enormous  pressure  to  which  the  body  is  subjected  in  this 
process  can  readily  be  understood.  As  regards  the  practical  bearings 
of  this  termination  of  shoulder  presentations,  all  that  need  be  said 
is,  that,  if  we  should  happen  to  meet  with  a  case  in  which  the 
shoulder  and  thorax  were  so  strongly  depressed  that  turning  was 
impossible,  and  in  which  it  seemed  that  nature  was  endeavoring  to 
effect  evolution,  we  would  be  justified  in  aiding  the  descent  of  the 
breech  by  traction  on  the  groin,  before  resorting  to  the  difficult  and 
hazardous  operation  of  embryotomy  or  decapitation. 

Treatment. — It  is  unnecessary  to  describe  specially  the  treatment 
of  shoulder  presentation,  since  it  consists  essentially  in  performing 
the  operation  of  turning,  which  is  fully  described  elsewhere.  It  is 
only  needfal  here  to  insist  on  the  advisability  of  performing  the 
operation  in  the  way  which  involves  the  least  interference  with  the 
uterus.  Hence  if  the  nature  of  the  case  be  detected  before  the  mem- 
branes are  ruptured,  an  endeavor  should  be  made — and  ought  gen- 
erally to  succeed — to  turn  by  external  manipulation  only.  If  we  can 
succeed  in  bringing  the  breech  or  head  over  the  os  in  this  way,  the 
case  will  be  little  more  troublesome  than  an  ordinary  presentation 
of  these  parts.     Failing  in  this,  turning  by  combined   external  and 


PRESENTATIONS  OF  SHOULDER,  ETC.  325 

internal  manipulation  should  be  attempted ;  and  the  introduction  of 
the  entire  hand  should  be  reserved  for  those  more  troublesome  cases 
in  which  the  waters  have  long  drained  away,  and  in  which  both 
these  methods  are  inapplicable. 

Should  all  these  means  fail,  we  must  resort  to  the  mutilation  of 
the  child  by  embryulcia  or  decapitation,  probably  the  most  difficult 
and  dangerous  of  all  obstetric  operations.^ 

Gom.plex  Presentations. — There  are  various  so-called  complex  pre- 
sentations in  which  more  than  one  part  of  the  foetal  body  presents. 
Thus  we  may  have  a  hand  or  a  foot  presenting  with  the  head,  or  a 
foot  and  hand  presenting  simultaneously.  The  former  do  not  neces- 
sarily give  rise  to  any  serious  difficulty,  for  there  is  generally  suffi- 
cient room  for  the  head  to  pass.  Indeed  it  is  unlikely  that  either 
the  hand  or  foot  should  enter  the  pelvic  brim  with  the  head,  unless 
the  head  was  unusually  small,  or  the  pelvis  more  than  ordinarily 
capacious.  As  regards  treatment,  it  is,  no  doubt,  advisable  to  make 
an  attempt  to  replace  the  hand  or  foot  by  pushing  it  gently  above 
the  head  in  the  intervals  between  the  pains,  and  maintaining  it  there 
until  the  head  be  fully  engaged  in  the  pelvic  cavity.  The  engage- 
ment of  the  head  can  be  hastened  by  abdominal  pressure,  which  will 
prove  of  great  value.  Failing  this,  all  we  can  do  is  to  place  the 
presenting  member  at  the  part  of  the  pelvis  where  it  will  least  im- 
pede the  labor,  and  be  the  least  subjected  to  pressure ;  and  that  will 
generally  be  opposite  the  temple  of  the  child.  As  it  must  obstruct 
the  passage  of  the  head  to  a  certain  extent,  the  application  of  the 
forceps  may  be  necessary.  When  the  feet  and  hand's  present  at  the 
same  time,  in  addition  to  the  confusing  nature  of  the  presentation 
from  so  many  parts  being  felt  together,  there  is  the  risk  of  the  hands 
coming  down,  and  converting  the  case  into  one  of  arm  presentation. 
It  is  the  obvious  duty  of  the  accoucheur  to  prevent  this  by  insuring 
the  descent  of  the  feet,  and  traction  should  be  made  on  them,  either 
with  the  fingers  or  with  a  lac,  until  their  descent,  and  the  ascent  of 
the  hands,  are  assured. 

Dorsal  Displacement  of  the  Arm. — In  connection  with  this  subject 
may  be  mentioned  the  curious  dorsal  displacement  of  the  arm  first 
described  by  Sir  James  Simpson,^  in  which,  the  forearm  of  the  child 
becomes  thrown  across  and  behind  the  neck.  The  result  is  the  for- 
mation of  a  ridge  or  bar,  which  prevents  the  descent  of  the  head  into 
the  pelvis  by  hitching  against  the  brim  (Fig.  116).  The  difficulty 
of  diagnosis  is  very  great,  for  the  cause  of  obstruction  is  too  high  lip 
to  be  felt.  But  if  we  meet  with  a  case  in  which  the  pelvis  is  roomy 
and  the  pains  strong,  and  yet  the  head  does  not  descend  after  an 
adequate  time,  a  full  exploration  of  the  cause  is  essential.  For  this 
purpose  we  would  naturally  put  the  patient  under  chloroform,  and 

'  [In  nine  instances  in  the  United  States,  the  Csesarean  section  has  been  performed 
under  these  circumstances  with  a  successful  result  to  the  mother  in  six.  One  who 
died  was  three  days  under  a  midwife  ;  another  twenty-six  hours,  the  woman  having 
ruptured  the  membranes  early  and  given  ergot ;  and  the  third  was  exhausted  by  long 
labor.     All  three  died  of  exhaustion. — Ed.] 

2  Selected  Obst.  Works,  vol.  i. 


526 


LABOR. 


pass  tlie  hand  sufficiently  high.  We  might  then  feel  the  arm  in  its 
abnormal  position.  That  was  what  took  place  in  a  case  under  my 
own  care,  in  which  I  failed  to  get  the  head  through  the  brim  with  the 
forceps,  and  eventually  delivered  by  turning.     The  same  course  was 


Fig.  116. 


Fig.  117. 


Dorsal  Displaceraentof  the  Arms. 


Dorsal  Displacement  of  the  Arms  in  Footling  Presentations. 
(After  Barnes.) 


adopted  by  my  friend  Mr.  Jardin  Murray  in  a  similar  case.^  Simp- 
son advises  that  the  arm  should  be  brought  down  so  as  to  convert 
the  case  into  an  ordinary  hand  and  head  presentation.  This,  if  the 
arm  be  above  the  brim,  must  always  be  difficult,  and  I  believed  the 
simpler  and  more  effective  plan  is  podalic  version.  A  similar  dis- 
placement may  cause  some  difficulty  in  breech  presentations,  and 
after  turning  (Fig.  117).  Delay  here  is  easier  of  diagnosis,  since  the 
obstacle  to  the  expulsion  will  at  once  lead  to  careful  examination. 
By  carrying  the  body  of  the  child  well  backwards,  so  as  to  enable  the 
finger  to  pass  behind  the  symphysis  pubis  and  over  the  shoulder,  it 
will  generally  be  easy  to  liberate  the  arm. 

Prolapse  of  the  U'mhiUcal  Cord. — It  occasionally  happens  that  the 
umbilical  cord  falls  down  past  the  presenting  part  (Fig.  118),  and  is 
apt  to  be  pressed  between  it  and  the  walls  of  the  pelvis.  The  conse- 
quence is,  that  the  foetal  circulation  is  seriously  interfered  with,  and 


»  Med.  Times  and  Gaz.,  1861. 


PRESENTATIONS    OF    SHOULDER,    ETC. 


827 


the  death  of  the  child  from  asphyxia  is  a  common  result.  Hence 
prolapse  of  the  funis  is  a  very  serious  complication  of  labor  in  so  far 
as  the  child  is  concerned. 


Fig.  118. 


Prolapse  of  the  Umbilical  Cord. 

Frequency. — Fortunately  it  is  not  a  very  frequent  occurrence. 
Churchill  calculates  that  out  of  over  105,000  deliveries  it  was  met 
with  once  in  240  cases,  and  Scanzoni  once  in  254:.  Its  frequency 
varies  much  under  different  circumstances,  and  in  different  places. 
We  find  from  Churchill's  figures  a  remarkalDle  difference  in  the  pro- 
portional number  of  cases  observed  in  France,  England,  and  Germany, 
viz.,  1  in  446|,  1  in  207^,  and  1  in  156,  respectively.  Great  as  is 
the  proportion  referred  to  Germany  in  these  figures,  it  has  been 
found  to  be  exceeded  in  special  districts.  Thus  Engelman  records  1 
case  out  of  94  labors  in  the  Lying-in  Hospital  at  Berlin,  and  Michaelis 
1  in  90  in  that  of  Kiel.  These  remarkable  differences  are  at  first 
sight  not  easy  to  account  for.  Dr.  Simpson  suggests,  wnth  consider- 
able show  of  probability,  that  the  difference  in  frequency  in  England, 
France,  and  Germany,  may  depend  on  the  varying  positions  in  which 
lying-in  women  are  placed  during  labor  in  each  country.  In  France, 
where,  although  the  patient  is  laid  on  her  back,  the  pelvis  is  kept 
elevated,  the  complication  occurs  least  frequently;  in  England,  where 
she  lies  on  her  side,  more  often;  and  in  Germany,  where  she  is 
placed  on  her  back  with  her  shoulders  raised,  most  often.  The 
special  frequency  of  prolapsed  funis  in  certain  districts,  as  in  Kiel,  is 
supposed  by  Engelman'  to  depend  on  the  prevalence  of  rickets,  and 
consequently  of  deformed  pelvis,  which   we  shall  presently  see  is 

'  Amer.  Journ.  of  Obst.,  vol.  vi. 


828  LABOR. 

probably  one  of  the  most  frequent  and  important   causes  of   the 
accident. 

Proynosis. — With  regard  to  the  danger  attending  prolapsed  funis, 
as  far  as  the  mother  is  concerned,  it  may  be  said  to  be  altogether 
unimportant ;  but  the  universal  experience  of  obstetricians  points  to 
the  great  risk  to  which  the  child  is  subjected.  Scanzoni  calculates 
that  45  per  cent,  only  of  the  children  were  saved  ;  Churchill  estimated 
the  number  at  47  per  cent. ;  thus,  under  the  most  favorable  circum- 
stances, this  complication  leads  to  the  death  of  more  than  half  the 
children,  Engelman  found  that  out  of  202  vertex  presentations  only 
36  per  cent,  of  the  children  survived.  The  mortality  was  not  nearly 
so  great  in  other  presentations ;  68  per  cent,  of  the  cases  in  which 
the  child  presented  with  the  feet  were  saved,  and  50  per  cent,  in 
original  shoulder  presentations.  The  reason  of  this  remarkable  dif- 
ference is,  doubtless,  that  in  vertex  presentations  the  head  fits  the 
pelvis  much  more  completely,  and  subjects  the  cord  to  much  greater 
pressure;  while  in  other  presentations  the  pelvis  is  less  completely 
filled,  and  the  interference  with  the  circulation  in  the  cord  is  not  so 
great.  Besides,  in  the  latter  case,  the  complication  is  detected  early, 
and  the  necessary  treatment  sooner  adopted. 

The  foetal  mortality  is  considerably  greater  in  first  labors;  a  result 
to  be  expected  on  account  of  the  greater  resistance  of  the  soft  parts, 
and  the  consequent  prolongation  of  the  labor. 

Causes. — The  causes  of  prolapse  of  the  funis  are  any  circumstances 
which  prevent  the  presenting  part  accurately  fitting  the  pelvic  brim. 
Hence  it  is  much  more  frequent  in  face,  breech,  or  shoulder,  than  in 
vertex  presentations,  and  is  relatively  more  common  in  footling  and 
shoulder  presentations  than  in  any  other.  Amongst  occasional  acci- 
dental predisposing  causes  may  be  mentioned  early  rupture  of  the 
membranes,  especially  if  the  amount  of  liquor  amnii  be  excessive,  as 
the  sudden  escape  of  the  fluid  washes  down  the  cord  ;  undue  length 
of  the  cord  itself;  or  an  unusually  low  placental  attachment.  Engel- 
man attaches  great  importance  to  slight  contraction  of  the  pelvis, 
and  states  that  in  the  Berlin  Lying-in  Hospital,  where  accurate 
measurements  of  the  pelvis  were  taken  in  all  cases,  it  was  almost 
invariably  found  to  exist.  The  explanation  is  evident,  since  one  of 
the  first  results  of  pelvic  contraction  is  to  prevent  the  ready  engage- 
ment of  the  presenting  part  in  the  pelvic  brim. 

Diagnosis. — The  diagnosis  of  cord  presentation  is  generally  devoid 
of  difficulty ;  but  if  tlie  membranes  are  still  unruptured,  it  may  not 
always  be  quite  easy  to  determine  the  precise  nature  of  the  soft 
structures  felt  through  them,  as  they  recede  from  the  touch.  If  the 
pulsations  of  the  coi'd  can  be  felt  through  the  membranes,  all  diffi- 
culty is  removed.  After  the  membranes  are  ruptured,  there  is 
nothing  that  it  can  well  be  mistaken  for. 

Importance  of  Determining  the  Pulsations  of  the  Cord. — The  im- 
portant point  to  determine  in  such  a  case  is  whether  the  cord  be 
pulsating  or  not;  for  if  pulsations  have  entirely  ceased,  the  inference 
is  that  the  child  is  dead,  and  the  case  may  then  be  left  to  nature 
without  further  interference.     It  is  of  importance,  however,  to  be 


PRESENTATIONS    OF    SHOULDER,    ETC. 


329 


careful ;  for,  if  the  examination  be  made  during  a  pain,  tbc  circula- 
tion might  be  only  temporarily  arrested.  The  examination,  there- 
fore, should  be  made  during  an  interval,  and  a  loop  of  the  cord 
pulled  down,  if  necessary,  to  make  ourselves  absolutely  certain  on 
this  point. 

Amount  of  Cord  Prolapsed. — The  amount  of  the  prolapse  varies 
much.  Sometimes  only  a  knuckle  of  the  cord,  so  small  as  to  escape 
observation,  is  engaged  between  the  pelvis  and  presenting  part. 
Under  such  circumstances  the  child  may  be  sacrificed  without  any 
suspicion  of  danger  having  arisen.  More  often  the  amount  pro- 
lapsed is  considerable  ;  sometimes  so  as  to  lie  in  the  vagina  in  a  long 
loop,  or  even  to  protrude  altogether  beyond  the  vulva. 

Treatment.— lu  the  treatment  the  great  indication  is  to  prevent  the 
cord  from  being  unduly  pressed  on,  and  all  our  endeavors  must  have 
this  object  in  view.  If  the  presentation  be  detected  before  the  full 
dilatation  of  the  cervix,  and  when  the  membranes  are  unruptured, 
we  must  try  to  keep  the  cord  out  of  the  way  ;  to  preserve  the  mem- 
branes intact  as  long  as  possible,  since  the  cord  is  tolerably  protected 
as  long  as  it  is  surrounded  by  the  liquor  amnii ;  and  to  secure  the 
complete  dilatation  of  the  os,  so  that  the  presenting  part  may  engage 
rapidly  and  completely. 

Postural  Treatment. — Much  may  be  done  at  this  time  by  the  pos- 
tural treatment,  which  we  chiefly  owe  to  the  ingenuity  of  Dr.  T.  Gail- 
lard  Thomas,  of  New  York,  whose  writings  familiarized  the  profession 
with  it,  although  it  appears  that  a  somewhat  similar  plan  had  been 

Fig.  119. 


Postiii-al  Treatment  of  Prolapse  of  the  Cord. 

occasionally  adopted  previously.  Dr.  Thomas's  method  is  based  on 
the  principle  of  causing  the  cord  to  slip  back  into  the  uterine  cavity 
by  its  own  weight.  For  this  purpose  the  patient  is  placed  on  her 
hands  and  knees,  with  the  hips  elevated,  and  the  shoulders  resting 
on  a  lower  level  (Fig.  119).  The  cervix  is  then  no  longer  the  most 
dependent  portion  of  the  uterus,  and  the  anterior  wall  of  the  uterus 
22 


330  LABOK. 

forms  an  inclined  plane  down  which  the  cord  slips.  The  success  of 
this  manoeuvre  is  sometimesVery  great,  but  by  no  means  always  so. 
It  is  most  likely  to  succeed  when  the  membranes  are  unruptured. 
If,  when  adopted,  the  cord  slip  away,  and  the  os  be  sufficiently  dilated, 
the  membranes  may  be  ruptured,  and  engagement  of  the  head  pro- 
duced by  properly  applied  uterine  pressure.  Sometimes  the  position 
is  so  irksome  that  it  is  impossible  to  resort  to  it.  Postural  treatment 
is  not  even  then  altogether  impossible,  for  by  placing  the  patient  on 
the  side  opposite  to  that  of  the  prolapse,  so  as  to  relieve  the  cord  as 
much  as  possible  from  pressure,  and  at  the  same  time  elevating  the 
hips  by  a  pillow,  it  may  slip  back.  Even  after  the  membranes  are 
ruptured,  postural  treatment  in  one  form  or  another  may  succeed; 
and,  as  it  is  simple  and  harmless,  it  should  certainly  be  always  tried. 
Attempts  at  reposition,  by  one  or  other  of  the  methods  described 
below,  may  also  occasionally  be  facilitated  by  trying  them  when  the 
patient  is  placed  in  the  knee-shoulder  position. 

Artificial  Reposition. — Failing  by  postural  treatment,  or  in  combi- 
nation with  it,  it  is  quite  legitimate  to  make  an  attempt  to  place  the 
cord  beyond  the  reach  of  dangerous  pressure  by  other  methods. 
Unfortunately  reposition  is  too  often  disappointing,  difficult  to  efi'ect, 
and  very  frequently,  even  when  apparently  successful,  shortly  fol- 
lowed by  a  fresh  descent  of  the  cord.  Provided  the  os  be  fully 
dilated,  and  the  presenting  head  engaged  in  the  pelvis  (for  reposition 
may  be  said  to  be  hopeless  when  any  other  part  presents),  perhaps 
the  best  way  is  to  attempt  it  by  the  hand  alone.  Probably  the 
simplest  and  most  effectual  method  is  that  recommended  by  McClin- 
tock  and  Hardy,  who  advise  that  the  patient  should  lie  on  the  oppo- 
site side  to  the  prolapsed  cord,  which  should  then  be  drawn  towards 
the  pubis  as  being  the  shallowest  part  of  the  pelvis.  Two  or  three 
iingers  may  then  be  used  to  push  the  cord  past  the  head,  and  as  high 
as  they  can  reach.  They  must  be  kept  in  the  pelvis  until  a  pain 
comes  on,  and  then  ^erj  gently  withdrawn,  in  the  hope  that  the  cord 
may  not  again  prolapse.  During  the  pain  external  pressure  may 
very  properly  be  applied  to  favor  descent  of  the  head.  This  manoeu- 
vre may  be  repeated  during  several  successive  pains,  and  may  event- 
ually succeed.  The  attempt  to  hook  the  cord  over  the  foetal  limbs, 
or  to  place  it  in  the  hollow  of  the  neck,  recommended  in  many 
works,  involves  so  deep  an  introduction  of  the  hand  that  it  is  obvi- 
ously impracticable. 

Instruments  used  for  Beposition.' — Various  complex  instruments 
have  been  invented  to  aid  reposition  (Fig.  120),  but  even  if  we  pos- 
sessed them  they  are  not  likely  to  be  at  hand  when  the  emergency 
arises.  A  simple  instrument  may  be  improvised  out  of  an  ordinary 
male  elastic  catheter,  by  passing  the  two  ends  of  a  piece  of  string 
through  it,  so  as  to  leave  a  loop  emerging  from  the  eye  of  the  cathe- 
ter. This  is  passed  through  the  loop  of  prolapsed  cord,  and  then 
fixed  in  the  eye  of  the  catheter  by  means  of  the  stilette.  The  cord 
is  then  pushed  up  into  the  uterine  cavity  by  the  catheter,  and  liber- 
ated by  withdrawing  the  stilette.     Another  simple  instrument  may 


PRESENTATIONS    OF    SHOULDER,   ETC. 


331 


be  made  bj  cutting  a  bole  in  a  piece  of  wbale-  Fig.  120. 

bone.  A  piece  of  tape  is  tben  passed  tbrougb  the 
loop  of  the  cord,  and  the  ends  threaded  through 
the  eye  cut  in  the  whalebone.  By  tightening  the 
tape  the  whalebone  is  held  in  close  apposition  to 
the  cord,  and  the  whole  is  passed  as  high  as  possi- 
ble into  the  uterine  cavity.  The  tape  can  easily 
be  liberated  by  pulling  one  end.  If  preferred,  the 
cord  can  be  tied  to  the  whalebone,  which  is  left  in 
utero  until  the  child  is  born.  Nothing  need  be 
said  as  to  the  various  other  methods  adopted  for 
keeping  up  the  cord,  such  as  the  insertion  of 
pieces  of  sponge,  or  tying  the  cord  in  a  bag  of  soft 
leather,  since  they  are  generally  admitted  to  be 
quite  useless. 

Treatment  when  Reposition  Fails. — It  only  too 
often  happens  that  all  endeavors  at  reposition  fail. 
The  subsequent  treatment  must  then  be  guided 
by  the  circumstances  of  the  case.  If  the  pelvis 
be  roomy,  and  the  pains  strong,  especially  in  a 
multipara,  we  may  often  deem  it  advisable  to  leave 
the  case  to  nature,  in  the  hope  that  the  head  may 
be  pushed  through  before  pressure  on  the  cord 
has  had  time  to  prove  fatal  to  the  child.  Under 
such  circumstances  the  patient  should  be  urged 
to  bear  down,  and  the  descent  of  the  head  pro- 
moted by  uterine  pressure,  so  as  to  get  the  second 
stage  completed  as  soon  as  possible.  If  the  head 
be  within  easy  reach,  the  application  of  the  forceps  is  quite  justi- 
fiable, since  delay  must  necessarily  involve  the  death  of  the  child. 
During  this  time  the  cord  should  be  placed,  if  possible,  opposite  one 
or  other  sacro-iliac  synchondrosis,  according  to  the  position  of  the 
head,  as  the  part  of  the  pelvis  where  there  is  most  room,  and  where 
the  pressure  would  consequently  be  least  prejudicial.  If  we  have  to 
do  with  a  case  in  which  the  head  has  not  descended  into  the  pelvis, 
and  postural  treatment  and  reposition  have  both  failed,  provided  the 
OS  be  fully  dilated,  and  other  circumstances  be  favorable,  turning 
would  undoubtedly  offer  the  best  chance  to  the  child.  This  treat- 
ment is  strongly  advocated  by  Engelman,  who  found  that  70  per 
cent,  of  the  children  delivered  in  this  way  were  saved.  There  can 
be  no  question  that,  so  far  as  the  interests  of  the  child  are  concerned, 
it  is,  under  the  circumstances  indicated,  by  far  the  best  expedient. 
Turning,  however,  is  by  no  means  always  devoid  of  a  certain  risk 
to  the  mother,  and  the  performance  of  the  operation,  in  any  particu- 
lar case,  must  be  left  to  the  judgment  of  the  practitioner.  A  fally 
dilated  os,  with  membranes  unruptured,  so  that  version  could  be 
performed  by  the  combined  method  without  the  introduction  of  the 
hand  into  the  uterus,  would  be  unquestionably  the  most  favorable 
state.  If  it  be  not  deemed  proper  to  resort  to  it,  all  that  can  be  done 
is  to  endeavor  to  save  the  cord  from  pressure  as  much  as  possible, 
by  one  or  other  of  the  methods  already  mentioned. 


Braun's    Apparatuu  for 
Eeplacing  ihe  Cord. 


332  LABOR. 


CHAPTEE   IX. 

PKOLONGED  AND  PEECIPITATE  LABORS. 

Amoxg  tlie  difficulties  connected  witli  parturition  there  are  none 
of  more  frequent  occurrence,  and  none  requiring  more  thorough 
knowledge  of  the  physiology  and  pathology  of  labor,  than  those 
arising  from  deficient  or  irregular  action  of  the  expulsive  powers. 
The  importance  of  studying  this  class  of  labors  will  be  seen  when  we 
consider  the  numerous  and  very  diverse  causes  which  produce  them. 

Evil  Effects  of  Prolonged  Labor. — -That  the  mere  prolongation  of 
labor  is  in  itself  a  serious  thing,  is  becoming  daily  more  and  more  an 
acknowledged  axiom  of  midwifery  practice  ;  and  that  this  is  so  is 
evident  when  we  contrast  the  statistical  returns  of  such  institutions 
as  the  Rotunda  Lying-in  Hospital  of  late  years,  with  those  which 
were  published  some  twenty  or  thirty  years  ago.  It  may  be  fairly 
assumed  that  the  practice  of  the  distinguished  heads  of  that  well- 
known  school  represents  the  most  advanced  and  scientific  opinion  of 
the  day  When  we  find  that,  less  than  thirty  years  ago,  the  forceps 
were  not  used  more  than  once  in  310  labors,  while  according  to  the 
report  for  1873  the  late  Master  applied  them  once  in  8  labors,  it  is 
apparent  how  great  is  the  change  which  has  taken  place. 

Causes  of  Prolonged  Lahor. — Labor  may  be  prcjlonged  from  an 
immense  number  of  causes,  the  principal  of  which  will  require  sepa- 
rate study.  Some  depend  simply  on  defective  or  irregular  action  of 
the  nterus  ;  others  act  by  opposing  the  expulsion  of  the  child,  as,  for 
example,  undue  rigidity  of  the  parturient  passages,  tumors,  bony 
deformity,  and  the  like.  Whatever  the  source  of  delay,  a  train  of 
formidable  symptoms  are  developed,  which  are  fraught  with  peril 
both  to  the  mother  and  the  child.  As  regards  the  mother,  they  vary 
much  in  degree,  and  in  the  rapidity  with  which  they  become  estab- 
lished. In  many  cases,  in  which  the  action  of  the  uterus  is  slight,  it 
may  be  long  before  serious  results  follow  ;  while  in  others,  in  which 
a  strongly-acting  organ  is  exhausting  itself  in  futile  endeavors  to 
overcome  an  obstacle,  the  worst  signs  of  protraction  may  come  on 
with  comparative  rapidity. 

The  Irifluence  of  the  Stage  of  Lahor  in  Protraction. — The  stage  of 
labor  in  which  delay  occurs  has  a  marked  effect  in  the  production  of 
untoward  symptoms.  It  is  a  well-established  fact  that  prolongation 
is  of  comparatively  small  consequence  to  either  the  mother  or  child 
in  the  first  stage,  when  the  membranes  are  still  intact,  and  when  the 
soft  parts  of  the  mother,  as  well  as  the  body  of  the  child,  are  pro- 
tected by  the  liquor  amnii  from  injurious  pressure  ;  Avhereas  if  the 
membranes  have  ruptured,  prolongation  becomes  of  the  utmost  im- 


PROLONGED  AND  PRECIPITATE  LABORS.  333 

portance  to  both  as  soon  as  the  head  has  entered  the  pelvis,  when 
the  uterus  is  strongly  excited  by  reflex  stimulation,  when  the  mater- 
nal soft  parts  are  exposed  to  continuous  pressure,  and  when  the 
tightly-contracted  uterus  presses  firmly  on  the  foetus  and  obstructs 
the  placental  circulation.  It  is  in  reference  to  the  latter  class  of  cases 
that  the  change  of  practice,  already  alluded  to,  has  taken  place,  with 
the  most  beneficial  results  both  to  the  mother  and  child. 

It  must  not  be  assumed,  however,  that  prolongation  of  labor  is 
never  of  any  consequence  until  the  second  stage  has  commenced. 
The  fallacy  of  such  an  opinion  was  long  ago  shown  by  Simpson,  who 
proved,  in  the  most  conclusive  way,  that  both  tlie  maternal  and  foetal 
mortality  were  greatly  increased  in  proportion  to  the  entire  length 
of  the  labor;  and  all  practical  accoucheurs  are  familiar  with  cases  in 
which  symptoms  of  gravity  have  arisen  before  the  first  stage  is 
concluded.  Still,  relatively  speaking,  the  opinion  indicated  is  un- 
doubtedly correct. 

In  the  present  chapter  we  have  to  do  only  with  those  causes  of 
delay  connected  with  the  expulsive  powers.  Inasmuch,  however,  as 
the  injurious  effects  of  protraction  are  similar  in  kind,  whatever  be 
the  cause,  it  will  save  needless  repetition  if  we  consider,  once  for  all, 
the  train  of  symptoms  that  arise  whenever  labor  is  unduly  prolonged. 

Delay  in  the  First  Sta.'je. — As  long  as  the  delay  is  in  the  first  stage 
only,  with  rare  exceptions,  no  symptoms  of  real  gravity  arise  for  a 
length  of  time  ;  it  may  be  even  for  days.  There  is  often,  however, 
a  partial  cessation  of  the  pains,  which  in  consequence  of  temporary 
exhaustion  of  nervous  force,  may  even  entirely  disappear  for  many 
consecutive  hours.  Under  such  circumstances,  after  a  period  of  rest, 
either  natural  or  produced  by  suitable  sedatives,  they  recur  with 
renewed  vigor, 

Symptoms  of  Protraction  in  the  Second  Stage. — -A  similar  temporary 
cessation  of  the  pains  may  often  be  observed  after  the  head  has 
passed  through  the  os  uteri,  to  be  also  followed  by  renewed  vigorous 
action  after  rest-  But  now  any  such  irregularity  must  be  much  more 
anxiously  watched.  In  the  majority  of  cases  any  marked  alteration 
in  the  force  and  frequency  of  the  pains  at  this  period  indicates  a 
much  more  serious  form  of  delay,  which  in  no  long  time  is  accom- 
panied by  grave  general  symptoms.  The  pulse  begins  to  rise,  the 
skin  to  become  hot  and  dry,  the  patient  to  be  restless  and  irritable. 
The  longer  the  delay,  and  the  more  violent  the  efforts  of  the  uterus 
to  overcome  the  obstacle,  the  more  serious  does  the  state  of  the 
patient  become.  The  tongue  is  loaded  with  fur,  and  in  the  worst 
cases,  dry  and  black  ;  nausea  and  vomiting  often  become  marked ; 
the  vagina  feels  hot  and  dry,  the  ordinary  abundant  mucous  secre- 
tion being  absent ;  in  severe  cases  it  may  be  much  swollen,  and  if 
the  presenting  part  be  firmly  impacted,  a  slough  may  even  form. 
Should  the  patient  still  remain  undelivered,  all  these  symptoms  be- 
come greatly  intensified ;  the  vomiting  is  incessant,  the  pulse  is  rapid 
and  almost  imperceptible,  low  muttering  delirium  supervenes,  and 
the  patient  eventually  dies  with  all  the  worst  indications  of  profound 
irritation  and  exhaustion. 


334  LABOR. 

So  formidable  a  train  of  symptoms,  or  even  the  slighter  degrees  of 
them,  should  never  occur  in  the  practice  of  the  skilled  obstetrician ; 
and  it  is  precisely  because  a  more  scientific  knowledge  of  the  process 
of  parturition  has  taught  the  lesson  that,  under  such  circumstances, 
prevention  is  better  than  cure,  that  earlier  interference  has  become  so 
much  more  the  rule. 

Those  who  taught  that  nothing  should  be  done  until  nature  had 
had  every  possible  chance  of  effecting  delivery,  and  who,  therefore, 
allowed  their  patients  to  drag  on  in  many  weary  hours  of  labor,  at 
the  expense  of  great  exhaustion  to  themselves,  and  imminent  risk  to 
their  oft'spring,  made  much  capital  out  of  the  time-honored  maxim 
that  "  meddlesome  midwifery  is  bad."  When  this  proverb  is  applied 
to  restrain  the  rash  interference  of  the  ignorant,  it  is  of  undeniable 
value ;  but,  when  it  is  quoted  to  prevent  the  scientific  action  of  the 
experienced,  who  know  precisely  when  and  why  to  interfere,  and 
who  have  accquired  the  indispensable  mechanical  skill,  it  is  sadly 
misapplied. 

State  of  the  Uterus  in  Protracted  Labor. — The  nature  of  the  pains 
and  the  state  of  the  uterus,  in  cases  of  protracted  labor,  are  peculiarly 
worthy  of  study,  and  have  been  very  clearly  pointed  out  by  Dr. 
Braxton  Hicks.'-  He  shows  that,  when  the  pains  have  apparently 
fallen  oft'  and  become  few  and  feeble,  or  have  entirely  ceased,  the 
uterus  is  in  a  state  of  continuous  or  tonic  contraction,  and  that  the 
irritation  resulting  from  this  is  the  chief  cause  of  the  more  marked 
symptoms  of  powerless  labor.  If,  in  a  case  of  the  kind,  the  uterus  be 
examined  by  palpation,  it  will  be  found  firmly  contracted  between 
the  pains.  The  correctness  of  this  observation  is  beyond  question, 
and  it  will,  no  doubt,  often  be  an  important  guide  in  treatment. 
Under  such  circumstances  instrumental  interference  is  imperatively 
demanded. 

Conditions  and  Causes  affecting  the  Expulsive  Poivers. — In  consider- 
ing the  causes  of  protracted  labor,  it  will  be  well  first  to  discuss  those 
which  affect  the  expulsive  powers  alone,  leaving  those  depending  on 
morbid  states  of  the  passages  for  future  consideration;  bearing  in 
mind,  however,  that  the  results,  as  regards  both  the  mother  and  the 
child,  are  identical,  whatever  maj^  be  the  cause  of  delay. 

Constitution  of  the  Patient. — The  general  constitutional  state  of  the 
patient  may  materially  influence  the  force  and  efficiency  of  the  pains. 
Thus  it  not  uufrequently  happens  that  they  are  feeble  and  ineffective 
in  women  of  very  weak  constitution,  or  who  are  much  exhausted  by 
debilitating  disease.  Cazeaux  pointed  out  that  the  effects  of  such 
general  conditions  are  often  more  than  counterbalanced  by  flaccidity 
and  want  of  resistance  of  the  tissues,  so  that  there  is  less  obstacle  to 
the  passage  of  the  child.  Thus  in  phthisical  patients  reduced  to  the 
last  stage  of  exhaustion,  the  labor  is  not  uufrequently  surprisingly 
easy. 

hifluence  of  Trojncal  Climates. — Long  residence  in  tropical  climates 
causes  uterine  inertia,  in  consequence  of  the  enfeebled  nervous  power 

'  Obst.  Trans.,  vol.  ix. 


PROLONGED  AND  PRECIPITATE  LABORS.  335 

it  produces.  It  is  a  common  observation  that  European  residents  in 
India  are  peculiarly  apt  to  suffer  from  past-partum  hemorrhage  from 
this  cause.  The  general  mode  of  life  of  patients  has  an  unquestion- 
able effect ;  and  it  is  certain  that  deficient  and  irregular  uteriue  action 
is  more  common  in  women  of  the  higher  ranks  of  society,  who  lead 
luxurious,  enervating  lives,  than  in  women  whose  habits  are  of  a 
more  healthy  character. 

Frequent  Child-hearing. — Tyler  Smith  lays  much  stress  on  frequent 
child-bearing  as  a  cause  of  inertia,  pointing  out  that  a  uterus  which 
has  been  very  frequently  subjected  to  the  changes  connected  with 
pregnancy,  is  unlikely  to  be  in  a  typically  normal  condition.  It  is 
doubtful,  however,  whether  the  uterus  of  a  perfectly  healthy  woman 
is  affected  in  this  way;  certainly,  if  child-bearing  had  undermined 
her  general  health,  the  labors  are  likely  to  be  modified  also. 

Age  of  Patient. — Age  has  a  decided  effect.  In  the  very  young  the 
.  pains  are  apt  to  be  irregular,  on  account  of  imperfect  development 
of  the  uterine  muscle.  Labor  taking  place  for  the  first  time  in 
women  advanced  in  life  is  also  apt  to  be  tedious,  but  not  by  any 
means  so  invariably  as  is  generally  believed.  The  apprehensions  of 
such  patients  are  often  agreeably  falsified,  and  where  delay  does 
occur,  it  is  probably  more  often  referable  to  rigidity  and  toughness 
of  the  parturient  passages  than  to  feebleness  of  the  pains. 

Disorders  of  the  Intestines. — Morbid  states  of  the  primse  vias  fre- 
quently cause  irregular,  painful,  and  feeble  contractions.  A  loaded 
state  of  the  rectum  has  often  a  remarkable  influence,  as  evidenced 
by  the  sudden  and  distinct  change  in  the  character  of  the  labor  which 
often  follows  the  use  of  suitable  remedies.  Undue  distension  of  the 
bladder  often  acts  in  the  same  way,  more  especially  in  the  second 
stage.  When  the  urine  has  been  allowed  to  accumulate  unduly,  the 
contraction  of  the  accessory  muscles  of  parturition  often  causes  such 
intense  suffering,  by  compressing  the  distended  viscus,  that  the  pa- 
tient is  absolutely  unable  to  bear  down.  Hence  the  labor  is  carried 
on  by  uterine  contractions  alone,  slowly,  and  at  the  expense  of  much 
suffering.  A  similar  interference  with  the  action  of  the  accessory 
muscles  is  often  produced  by  other  causes.  Thus  if  labor  comes  on 
when  the  patient  is  suffering  from  bronchitis  or  other  chest  disease, 
she  may  be  quite  unable  to  fix  the  chest  by  a  deep  inspiration,  and 
the  diaphragm  and  other  accessory  muscles  cannot  act.  In  the  same 
way  they  may  be  prevented  from  acting  when  the  abdomen  is  occu- 
pied by  an  ovarian  tumor,  or  by  ascitic  fluid. 

Mental  conditions  have  a  very  marked  effect.  This  is  so  commonly 
observed  that  it  is  familiar  to  the  merest  beginner  in  midwifery  prac- 
tice. The  fact  that  the  pains  often  dimmish  temporarily  on  the^ 
entrance  of  the  accoucheur  is  known  to  every  nurse ;  and  so  also 
undue  excitement,  the  presence  of  too  many  people  in  the  room, 
over-much  talking,  have  often  the  same  prejudicial  effect.  Depres- 
sion of  mind,  as  in  unmarried  women,  and  fear  and  despondency  in 
women  who  have  looked  forward  with  apprehension  to  their  labor, 
are  also  common  causes  of  irregular  and  defective  action. 


336  LABOR. 

Excessive  Amount  of  Liquor  Amnii. — Undue  distension  of  the  uterus 
from  an  excessive  amount  of  liquor  amnii  not  unfrequently  retards 
the  first  stage,  by  preventing  the  uterus  from  contracting  efficiently. 
"When  this  exists,  the  pains  are  feeble  and  have  little  effect  in  dilating 
the  cervix  beyond  a  certain  degree.  This  cause  may  be  suspected, 
when  undue  protraction  of  the  first  stage  is  associated  with  an  unusu- 
ally large  size  and  marked  fluctuation  of  the  uterine  tumor,  through 
which  the  foetal  limbs  cannot  be  made  out  on  palpation.  On  vaginal 
examination,  the  lower  segment  of  the  uterus  will  be  found  to  be 
very  rounded  and  prominent,  while  the  bag  of  membranes  will  not 
bulge  through  the  os  during  the  acme  of  the  pain. 

Malpositions  of  the  Uterus. — A  somewhat  similar  cause  is  undue 
obliquity  of  the  uterus,  which  prevents  the  pains  acting  to  the  best 
mechanical  advantage,  and  often  retards  the  entry  of  the  presenting 
part  into  the  brim.  The  most  common  variety  is  ante  version,  result- 
ing from  excessive  laxity  of  the  abdominal  parietes,  which  is  espe- 
cially found  in  women  who  have  borne  many  children.  Sometimes 
this  is  so  excessive  that  the  fundus  lies  over  the  pubis,  and  even 
projects  downwards  towards  the  patient's  knees.  The  consequence 
is  that,  when  labor  sets  in,  unless  corrective  means  be  taken,  the 
pains  force  the  head  against  the  sacrum,  instead  of  directing  it  into 
the  axis  of  the  pelvic  inlet.  Another  common  deviation  is  lateral 
obliquity,  a  certain  degree  of  which  exists  in  almost  all  cases,  but 
sometimes  it  occurs  to  an  excessive  degree.  Either  of  these  states 
can  readily  be  detected  by  palpation  and  vaginal  examination  com- 
bined. In  the  former  the  os  may  be  so  high  up,  and  tilted  so  far 
backwards,  that  it  may  be  at  first  difficult  to  reach  it  at  all. 

Irregular  and  Spasmodic  Pains. — Besides  being  feeble,  the  uterine 
contractions,  especially  in  the  first  stage,  are  often  irregular  and 
spasmodic,  intensely  painful,  but  producing  little  or  no  efiect  on  the 
progress  of  the  labor.  This  kind  of  case  has  been  alread}^  alluded 
to  in  treating  of  the  use  of  anaesthetics  (p.  289),  and  is  verj^  com- 
mon in  highly  nervous  and  emotional  women  of  the  upper  classes. 
Such  irregular  contractions  do  not  necessarily  depend  on  mental 
causes  alone,  and  they  are  often  produced  by  conditions  producing 
irritation,  such  as  loaded  bowels,  too  early  rupture  of  the  membranes, 
and  the  like.  Dr.  Trenholme,  of  Montreal,^  believes  that  such  irregu- 
lar pains  most  frequently  depend  on  abnormal  adhesions  between 
the  decidua  and  the  uterine  walls,  which  interfere  with  the  proper 
dilatation  of  the  os,  and  he  has  related  some  interesting  cases  in 
support  of  this  theory. 

Treatment. — The  mere  enumeration  of  these  various  causes  of  pro- 
tracted labor  will  indicate  the  treatment  required.  Some  of  them, 
such  as  the  constitutional  state  of  the  patient,  age,  or  mental  emotion, 
it  is,  of  course,  beyond  the  power  of  the  practitioner  to  influence  or 
modify;  but  in  every  case  of  feeble  or  irregular  uterine  action,  a 
careful  investigation  should  be  made  with  the  view  of  seeing  if  any 
removable  cause  exist.     For  example,  the  effect  of  a  large  enema, 

1  Obst.  Trans.  1873. 


PROLONGED  AND  PRECIPITATE  LABORS.  337 

when  we  suspect  the  existence  of  a  loaded  rectum,  is  often  very  re- 
maricable ;  the  pains  frequently  almost  immediately  changing  in 
character,  and  a  previously  lingering  labor  being  rapidly  terminated. 

Excessive  distension  of  the  uterus  can  only  be  treated  by  artificial 
evacuation  of  the  liquor  amnii ;  and  afler  this  is  done,  the  character 
of  the  pains  often  rapidly  changes.  This  expedient  is  indeed  often 
of  considerable  value  in  cases  in  which  the  cervix  has  dilated  to  a 
certain  extent,  but  in  which  no  further  progress  is  made,  especially 
if  the  bag  of  membranes  does  not  protrude  through  the  os  during 
the  pains,  and  the  cervix  itself  is  soft,  and  apparently  readily  dilata- 
ble. Under  such  circumstances,  rupture  of  the  membranes,  even 
before  the  os  is  fully  dilated,  is  often  very  useful. 

Adlierent  Membranes. — If  we  have  reason  to  suspect  morbid  adhe- 
sions between  the  membranes  and  the  uterine  walls,  an  endeavor 
must  be  made  to  separate  them  by  sweeping  the  finger  or  a  flexible 
catheter  round  the  internal  margin  of  the  os,  or  puncturing  the  sac. 
The  former  expedient  has  been  advocated  by  Dr.  Inglis,^  as  a  means 
of  increasing  the  pains  when  the  first  stage  is  yery  tedious,  and  I 
have  often  practised  it  with  marked  success.  Treuholme's  observa- 
tion affords  a  rationale  of  its  action.  The  manoeuvre  itself  is  easily 
accomplished,  and,  provided  the  os  be  not  very  high  in  the  pelvis 
does  not  give  any  pain  or  discomfort  to  the  patient. 

Uterine  Deviations. — Attention  should  always  be  paid  to  remedy- 
ing any  deviations  of  the  uterus  from  its  proper  axis.  If  this  be 
lateral,  the  proper  coarse  to  pursue  is  to  make  the  patient  lie  on  the 
opposite  side  to  that  towards  which  the  organ  is  pointing.  In  the 
more  common  anterior  deviation  she  should  lie  on  her  back,  so  that 
the  uterus  may  gravitate  towards  the  spine,  and  a  firm  abdominal 
bandage  should  be  applied.  This  prevents  the  organ  from  falling- 
forwards,  while  its  pressure  stimulates  the  muscular  fibres  to  in- 
creased action ;  hence  it  is  often  very  serviceable  when  the  pains  are 
feeble,  even  if  there  be  no  anteversion. 

Temiporary  Exhaustion. — In  a  frequent  class  of  cases,  especiallv  in 
the  first  stage,  the  pains  diminish  in  force  and  frequency  from  fatigue, 
and  the  indication  then  is  to  give  a  temporary  rest,  after  which  they 
recommence  with  renewed  vigor.  Hence  an  opiate,  such  as  20 
minims  of  Battley's  solution,  which  often  acts  quickest  when  given 
in  the  form  of  enema,  is  frequently  of  the  greatest  possible  value. 
If  this  secure  a  few  hours'  sleep,  the  patient  will  generally  awake 
much  refreshed  and  invigorated.  It  is  important  to^distinguish  this 
variety  of  arrested  pain  from  that  dependent  on  actual  exhaustion ; 
and  this  can  be  dcme  by  attention  to  the  general  condition  of  the 
patient,  and  especially  by  observing  that  the  uterus  is  soft  and  flaccid 
in  the  intervals  between  the  pains,  and  that  there  is  none  of  the  tonic 
contraction,  indicated  by  persistent  hardness  of  the  uterine  parietes. 
When  the  pains  are  irregular,  spasmodic,  and  excessively  painful, 
without  producing  any  real  effect,  opiates,  are  also  of  great  service ; 
and  it  is  under  such  circumstances  that  chloral  is  especially  valuable. 

'  Sydenham  Society's  Year-Book,  1869. 


338  LABOR. 

Oxytocic  Remedies. — Still  a  large  number  of  cases  will  arise  in 
which  the  absence  of  all  repiovable  causes  has  been  ascertained,  and 
in  which  the  pains  are  feeble  and  ineft'ective.  We  must  now  proceed 
to  discuss  their  management.  The  fault  being  the  want  of  sufncient 
contraction,  the  first  indication  is  to  increase  the  force  of  the  pains. 
Here  the  so-called  oxytocic  remedies  come  into  action  ;  and,  although 
a  large  number  of  these  have  been  used  from  time  to  time,  such  as 
borax,  cinnamon,  quinine^  and  galvanism,  practically,  the  only  one 
in  which  any  reliance  is  now  placed  is  the  ergot  of  rye.  This  has 
long  been  the  favorite  remedy  for  deficient  uterine  action,  and  it  is  a 
powerful  stimulant  of  the  uterine  fibres.  It  has,  however,  very 
serious  disadvantages,  and  it  is  very  questionable  whether  the  risks 
to  both  mother  and  child  do  not  more  than  counterbalance  any  ad- 
vantages attending  its  use.  The  ergot  is  given  in  doses  of  15  or  20 
grains  of  the  freshly  powdered  drug  diffused  in  warm  water,  or  in 
the  more  convenient  form  of  the  liquid  extract  in  doses  of  from  20 
to  30  minims,  or,  still  better,  in  the  form  of  ergotine  injected  hypo- 
dermically,  3  to  4  minims  of  the  hypodermic  solution  being  used  for 
the  purpose.  In  about  fifteen  minutes  after  its  administration  the 
pains  generally  increase  greatly  in  force  and  frequency,  and  if  the 
head  be  low  in  the  pelvis,  and  if  the  soft  parts  offer  no  resistance, 
the  labor  may  be  rapidlj^  terminated. 

Objections  to  its  Use. — Were  its  use  always  followed  by  this  effect 
there  would  be  little  or  no  objection  to  its  administration.  The  pains, 
however,  are  different  from  those  of  natural  labor,  being  strong,  per- 
sistent, and  constant.  Its  effect,  indeed,  is  to  produce  that  very  state 
of  tonic  and  persistent  uterine  contraction,  which  has  been  already 
pointed  out  as  one  of  the  chief  dangers  of  protracted  labor.  Hence 
if,  from  any  cause,  the  exliibition  of  the  drug  be  not  followed  by  rapid 
delivery,  a  condition  is  produced  which  is  serious  to  the  mother ; 
and  which  is  extremely  perilous  to  the  child,  on  account  of  the  tonic 
contraction  of  the  muscular  fibres  obstructing  the  utero-placental 
circulation.  Dr.  Hardy  found  that  soon  the  foetal  pulsations  fall  to 
100,  and,  if  delivery  be  long  delayed,  they  commence  to  intermit. 
He  also  observed  that  when  this  occurred  the  child  was  always  born 

'  [Quinia  as  an  oxytocic  deserves  more  than  a  passing  notice,  having  been  very 
carefully  tested  by  several  leading  obstetricians  of  Pliiladelpliia  within  a  few  years. 
According  to  the  observations  of  Dr.  Albert  H.  Smith,  in  42  cases  of  parturition,  it 
presents  the  following  peculiar  characteristics. 

It  has  no  power  in  itself  to  excite  uterine  contractions,  but  simply  acts  as  a  general 
stimulant,  and  promoter  of  vital  energy,  and  functional  activity. 

In  normal  labor  at  full  term,  its  administration  in  a  dose  of  fifteen  grains,  is  usually 
followed  in  as  many  minutes  by  a  decided  increase  in  the  force  and  frequency  of  the 
uterine  contractions,  changing  in  some  instances  a  tedious  exhausting  labor  into  one 
of  rapid  energy,  advancing  to  an  early  completion. 

It  promotes  the  permanent  tonic  contraction  of  the  uterus,  after  the  expulsion  of 
the  placenta  ;  women  that  had  flooded  in  former  labors  escaping  entirely,  there  not 
having  been  an  instance  of  post-partum  hemorrhage  in  the  whole  42  cases. 

It  also  diminishes  the  lochial  flow  where  it  had  been  excessive  in  former  labors,  the 
change  being  remarked  upon  by  the  patients  ;  and  consequently  lessens  the  severity 
of  the  after-pains. 

Cinchonism  is  very  rarely  observed  as  an  eff'ect  of  large  doses  in  parturient  women. 
—Ej).— Trans.  Coll.  Phys.  Philad.  1875,  p.  183.] 


PKOLONGED  AND  PRECIPITATE  LABORS.  339 

dead,  and  found  that  the  number  of  still-born  cliildren  after  ergot 
has  been  exhibited  was  very  large  ;  for  out  of  80  cases  in  which  he 
gave  it  in  tedious  labor,  only  10  of  the  children  were  born  alive. 
Nor  is  its  use  by  any  means  free  from  danger  to  the  mother ;  a  not 
inconsiderable  number  of  cases  of  rupture  of  the  uterus  have  been 
attributed  to  its  incautious  use.  Hence,  if  it  is  to  be  given  at  all,  it  is 
obvious  that  it  must  be  with  strict  limitations,  and  after  careful  con- 
sideration. It  is  worthy  of  note  that  in  the  Bethesda  Hospital  in 
Dublin,  the  use  of  ergot  as  an  oxytocic  before  delivery,  has  been  pro- 
hibited by  the  present  trustees. 

Limitations  to  its  Use. — The  cardinal  point  to  remember  is  that  it 
is  absolutely  contraindicated  unless  the  absence  of  all  obstacles  to 
rapid  delivery  has  been  ascertained.  Hence,  it  is  only  allowable 
when  the  first  stage  is  over,  and  the  os  full}^  dilated ;  when  the  ex- 
perience of  former  labors  has  proved  the  pelvis  to  be  of  ample  size  ; 
and  when  the  perineum  is  soft  and  dilatable.  Perhaps,  as  has  been 
suggested,  the  administration  of  small  doses  of  from  5  to  10  minims 
of  the  liquid  extract  every  ten  minutes,  until  more  energetic  action 
set  in,  might  obviate  some  of  these  risks. 

Manual  Pressure  as  a  Means  of  Increasing  tlie  Uterine  Contractions. 
— Hwe  had  no  other  means  of  increasing  defective  uterine  contrac- 
tions at  our  disposal,  and  if  the  choice  lay  only  betAveen  the  use  of 
ergot  and  instrumental  delivery,  there  might  not  be  so  much  objec- 
tion to  a  cautious  use  of  the  drug  in  suitable  cases.  We  have,  how- 
ever, a  means  of  increasing  the  force  of  the  uterine  contractions  so 
much  more  manageable,  and  so  much  more  resembling  the  natural 
process,  that  I  believe  it  to  be  destined  to  entirely  supersede  the  ad- 
ministration of  ergot.  This  is  the  application  of  manual  pressure  to 
the  uterus  through  the  abdomen,  an  expedient  that  has  of  late  years 
been  much  used  in  Germany,  and  has  begun  to  be  employed  in  English 
practice.  I  believe,  therefore,  that  ergot  should  be  chiefly  used  for  the 
purpose  of  exciting  uterine  contraction  after  delivery,  when  its  pecu- 
liar property  of  promoting  tonic  contraction  is  so  valuable,  and  that 
it  should  rarely,  if  at  all,  be  employed  before  the  birth  of  the  child. 

The  systenuitic  use  of  uterine  pressure  as  an  oxytocic  was  first 
prominently  brought  under  the  notice  of  the  profession  by  Kristeller, 
under  the  name  of  "  Expressio  Foetus,"  although  it  has  been  used  in 
various  forms  from  time  immemorial.  Albucasis,  for  example,  was 
clearly  acquainted  with  its  use,  and  referred  to  it  in  the  folloAving 
terms :  Cum  ergo  vides  ista  signa,  tunc  oportet,  ut  comprimatur 
uterus  ejus  ut  descendat  embryo  velociter,"  There  are  some  curious 
obstetric  customs  among  various  nations,  which  probably  arose  from 
a  recognition  of  its  value ;  as,  for  example,  the  mode  of  delivery 
adopted  among  the  Kalmucks,  where  the  patient  sits  at  the  foot  of 
the  bed,  while  a  woman  seated  behind  her,  seizes  her  round  the  waist 
and  squeezes  the  uterus  during  the  pains.  Amongst  the  Japanese, 
Siamese,  North  American  Indians,  and  many  other'nations,  pressure, 
applied  in  various  ways  is  habitually  used. 

Kristeller  maintains  that  it  is  possible  to  effect  the  complete  ex- 
pulsion of   the  child  by  properly  applied  pressure,  even   when  the 


340  LABOR. 

pains  are  entirely  absent.  Strange  as  this  may  appear  to  those  who 
are  not  familiar  with  the  efl'ects  of  pressure,  I  believe  that,  under  ex- 
ceptional circumstance,  when  the  pelvis  is  very  capacious,  and  the 
soft  parts  offer  but  slight  resistance,  it  can  be  done.  I  have  delivered 
in  this  way  a  patient  whose  friends  would  not  permit  me  to  apply 
the  forceps,  when  I  could  not  recognize  the  existence  of  any  uterine 
contraction  at  all,  the  foetus  being  literally  squeezed  out  of  the  uterus. 
It  is  not,  however,  as  replacing  absent  pains,  but  as  a  means  of  in- 
tensifying and  prolonging  the  effects  of  deficient  and  feeble  ones,  that 
pressure  finds  its  best  application. 

Its  effects  are  often  very  remarkable,  especially  in  women  of  slight 
build,  where  there  is  but  little  adipose  tissue  in  the  abdominal  walls, 
and  not  much  resistance  in  the  pelvic  tissues.  If  the  finger  be  placed 
on  the  head  while  pressure  is  applied  to  the  uterus,  a  very  marked 
descent  can  readily  be  felt,  and  not  infrequently  two  or  three  appli- 
cations will  force  the  head  on  to  the  perineum.  There  are,  however, 
certain  conditions  when  it  is  inapplicable,  and  the  existence  of  which 
should  contraindicate  its  use.  Thus  if  the  uterus  seem  unusually 
tender  on  pressure,  and,  a  fortiori^  if  the  tonic  contraction  of  exhaus- 
tion be  present,  it  is  inadmissible.  So  also  if  there  be  any  obstruction 
to  rapid  delivery,  either  from  narrowing  of  the  pelvis  or  rigidity  of 
the  soft  parts,  it  should  not  be  used.  The  cases  suitable  for  its 
application  are  those  in  which  the  head  or  breech  is  in  the  pelvic 
cavity,  and  the  delaj'  is  simply  due  to  a  want  of  sufiiciently  strong 
expulsive  action. 

Mode  of  Ap2)licaiion. — It  may  be  applied  in  two  ways.  The  better 
is  to  place  the  patient  on  her  back  at  the  edge  of  the  bed,  and  spread 
the  palms  of  the  hands  on  either  side  of  the  fundus  and  body  of  the 
uterus,  and,  when  a  pain  commences,  to  make  firm  pressure  during 
its  continuance  downwards  and  backwards  in  the  direction  of  the 
pelvic  inlet.  As  the  contraction  passes  off  the  pressure  is  relaxed, 
and  again  resumed  when  a  fresh  pain  begins.  In  this  way  each  pain 
is  greatly  intensified,  and  its  efl^ect  on  the  progress  of  the  foetus  much 
increased.  It  is  not  essential  that  the  patient  should  lie  on  her  back. 
A  useful,  although  not  so  great,  amount  of  pressure  can  be  applied 
when  she  is  lying  in  the  ordinary  obstetric  position  on  her  left  side, 
the  left  hand  being  spread  out  over  the  fundus,  leaving  the  right  free 
to  watch  tlie  progress  of  the  presenting  part  per  vaginam. 

Special  Value  of  Uterine  Pressure.- — The  special  value  of  this 
method  of  treating  ineftective  pains  is,  that  the  amount  and  fre- 
quency of  the  pressure  are  completely  within  the  control  of  the 
practitioner,  and  are  capable  of  being  regulated  to  a  nicety  in  ac- 
cordance with  the  requirements  of  each  particular  case.  It  has  the 
peculiar  advantage  of  closely  imitating  the  natural  means  of  delivery, 
and  of  being  absolutely  without  risk  to  the  child  :  nor  is  there  any 
reason  to  think  that  it  is  capable  of  injuring  the  mother.  At  least  I 
may  safely  say  that,  out  of  the  large  number  of  cases  in  which  I 
have  used  it,  1  have  never  seen  one  in  which  I  had  the  least  reason 
to  think  that  it  had  proved  hurtful.  Of  course,  it  is  essential  not  to 
use  undue  roughness:  firm  and  even  strong  pressure  may  be  em- 


PROLONGED    AND    PRECIPITATE    LABORS.  341 

ployed,  but  that  can  be  done  without  being  rougli ;  and,  as  its  appli- 
cation is  always  intermittent,  there  is  no  time  for  it  to  intiict  any 
injury  on  the  uterine  tissues. 

Pressure  is  specially  valuable  when  it  is  desirable  to  intensify 
feeble  pains.  It  may  be  serviceably  employed  when  the  pains  are 
altogether  absent,  to  imitate  and  replace  them,  provided  there  be 
nothing  but  the  absence  of  a  vis  ci  teryo  to  prevent  speedy  delivery. 
In  such  cases  an  endeavor  should  be  made  to  imitate  the  pains  as 
closely  as  possible,  by  applying  the  pressure  at  intervals  of  four  or 
five  minutes,  and  entirely  relaxing  it  after  it  has  been  applied  for  a 
few  seconds. 

Change  of  Professional  Opinion  as  to  Instrumental  Delivery. — 
When  all  these  means  fail  we  have  then  left  the  resource  of  instru- 
mental aid,  and  we  have  now  to  consider  the  indications  for  the  use 
of  the-forceps  under  such  circumstances.  It  has  been  already  pointed 
out  that  professional  opinion  on  this  point  has  been  undergoing  a 
marked  change ;  and  that  it  is  now  recognized  as  an  axiom  by  the 
most  experienced  teachers  that,  when  we  are  once  convinced  that  the 
natural  efforts  are  failing,  and  are  unlikely  to  effect  delivery,  except 
at  the  cost  of  long  delay,  it  is  far  better  to  interfere  soon  rather  than 
late,  and  thus  prevent  the  occurrence  of  the  serious  symptoms  ac- 
companying protracted  labor.  The  recent  important  debate  on  the 
use  of  the  forceps  at  the  Obstetrical  Society  of  London  remarkably 
illustrated  these  statements,  for,  while  there  was  much  difference  of 
opinion  as  to  the  advisability  of  applying  the  forceps  when  the  head 
was  high  in  the  pelvis,  a  class  of  cases  not  now  under  consideration, 
it  was  very  generally  admitted  that  the  modern  teaching  was  based 
on  correct  scientific  grounds.  This  is,  of  course,  directly  opposed  to 
the  view  so  long  taught  in  our  standard  works,  in  which  instrumental 
interference  was  strictly  prohibited  unless  all  hope  of  natural  delivery 
was  at  end ;  and  in  which  the  commencement  at  least,  if  not  the 
complete  establishment,  of  symptoms  of  exhaustion,  was  considered 
to  be  the  only  justification  for  the  application  of  forceps  in  lingering 
labor. 

Views  of  Dr.  Johnston  on  the  Use  of  the  Forceps. — The  reasons  Avhich 
have  led  the  late  distinguished  Master  of  the  Eotunda  Hospital  to  a 
more  frequent  use  of  the  forceps  are  so  well  expressed  in  his  report 
for  1872,  that  I  venture  to  quote  them,  as  the  best  justification  for  a 
practice  that  many  practitioners  of  the  older  school  will,  no  doubt, 
be  inclined  to  condemn  as  rash  and  hazardous.  He  saj^s  :^  "  Our 
established  rule  is  that  so  long  as  nature  is  able  to  effect  its  purpose 
without  prejudice  to  the  constitution  of  the  patient,  danger  to  the 
soft  parts,  or  the  life  of  the  child,  we  are  in  duty  bound  to  allow  the 
labor  to  proceed;  but  as  soon  as  we  find  the  natural  efforts  are  be- 
ginning to  fail,  and  after  having  tried  the  milder  means  for  relaxing 
the  parts  or  stimulating  the  uterus  to  increased  action,  and  the  de- 
sired effects  not  being  produced,  we  consider  we  are  in  duty  bound 

'   Fourtli  Clinical  Report  of  the  Rotunda  Lying-in  Hospital  for  the  ye^^r  ending 

1872. 


342  LABOR. 

to  adopt  still  prompter  measures,  and  by  our  timely  assistance  relieve 
the  sufferer  from  her  distress  and  her  offspring  from  an  imminent 
death.  Why,  may  I  ask,  should  we  permit  a  fellow  creature  to 
undergo  hours  of  torture  when  we  have  the  means  of  relieving  her 
within  our  reach?  Why  should  she  he  allowed  to  waste  her  strength, 
and  incur  the  risks  consequent  upon  long  pressure  of  the  head  on  the 
soft  parts,  the  tendency  to  inflammation  and  sloughing,  or  the  danger 
of  rupture,  not  to  speak  of  the  poisonous  miasm  which  emanates 
from  an  inflammatory  state  of  the  passages,  the  result  of  tedious 
labor,  and  which  is  one  of  the  fertile  causes  of  puerperal  fever  and 
all  its  direful  effects,  attributed  by  some  to  the  influence  of  being 
confined  in  a  large  maternity,  and  not  to  its  proper  source,  i.  e.,  the 
labor  being  allowed  to  continue  till  inflammatory  symptoms  appear? 
The  more  we  consider  the  benefits  of  timely  interference,  and  the 
good  results  which  follow  it,  the  more  are  we  induced  to  pursue  the 
system  we  have  adopted,  and  to  inculcate  to  those  we  are  instructing 
the  advantages  to  be  gained  by  such  practice,  both  in  saving  the  life 
of  the  child  as  well  as  securing  the  greater  safety  of  the  mother." 
It  would  be  impossible  to  put  the  matter  in  a  stronger  or  clearer 
light,  and  I  feel  confident  that  these  views  will  be  indorsed  by  all 
who  have  adopted  the  more  modern  practice. 

Effect  of  Early  Interference  on  the  Infantile  Mortality. — In  the  first 
edition  of  this  work  I  used  the  statistics  of  Dr.  Hamilton,  of  Falkirk, 
and  other  modern  writers,  as  proving  that  a  more  frequent  use  of  the 
forceps  than  has  been  customary,  diminished  in  a  remarkable  degree 
the  infantile  mortality.  Dr.  Galabin^  has  recently  published  an  ad- 
mirable paper  on  this  subject,  in  which,  by  a  careful  criticism  of 
these  figures,  he  has,  I  think,  proved  that  the  conclusions  drawn  from 
them  are  open  to  doubt,  and  that  the  saving  of  infantile  life  follow- 
ing more  frequent  forceps  delivery  is  by  no  means  so  great  as  I  had 
supposed.  Dr.  Eoper,  in  his  remarks  in  the  recent  debate  in  the 
Obstetrical  Society,  brought  forv/ard  some  strong  arguments  in  sup- 
port of  the  same  view.  This,  however,  does  not  in  any  way  touch 
the  main  points  at  issue  referred  to  in  the  preceding  paragraph. 

Possible  DawjZTs  Attending  the  Use  of  the  Force-ps. — It  is,  of  course, 
right  that  we  should  consider  the  opposite  point  of  view,  and  reflect 
on  the  disadvantages  which  may  attend  the  interference  advocated. 
Here  I  should  point  out  that  I  am  now  talking  only  of  the  use  of  the 
forceps  in  simple  inertia,  when  the  head  is  low  in  the  pelvic  cavity, 
and  when  all  that  is  wanted  is  a  slight  vis  d,  fronte  to  supplement 
the  deficient  vis  a  tergo.  The  use  of  the  instrument  when  the  head 
is  'arrested  high  in  the  pelvis,  or  in  cases  of  deformity,  or  before  the 
OS  uteri  is  completely  expanded,  is  an  entirely  different  and  much 
more  serious  matter,  and  does  not  enter  into  the  present  discussion. 
The  chief  question  to  decide  is  if  there  be  sufficient  risk  to  the  mother 
to  counterbalance  that  of  delay.  It  will,  of  course,  be  conceded  by 
all,  that  the  forceps  in  the  hands  of  a  coarse,  bungling,  and  ignorant 
practitioner,  who  has  not  studied  the  prooer  mode  of  operating,  may 

'  Obstetrical  Journal,  December,  1877. 


PROLONGED  AND  PRECIPITATE  LABORS.  3-43 

easily  inflict  serous  damage.  The  possibility  of  inflicting  injury  in 
this  way  should  act  as  a  warning  to  every  obstetrician  to  make  him- 
self thoroughly  acquainted  with  the  proper  mode  of  using  the  instru- 
ment, and  to  acquire  the  manual  skill  which  practice  and  the  study 
of  the  mechanism  of  delivery  will  alone  give ;  but  it  can  hardly  be 
used  as  an  argument  against  its  use.  If  that  were  admitted,  surgical 
iuterference  of  any  kind  would  be  tabooed,  since  there  is  none  that 
ignorance  and  incapacity  might  not  render  dangerous. 

Assuming,  therefore,  that  the  practitioner  is  able  to  apply  the  for- 
ceps skilfully,  is  there  any  inherent  danger  in  its  use  ?  I  think  all 
who  dispassionately  consider  the  question  must  admit  that,  in  the 
class  of  cases  alluded  to,  the  operation  is  so  simple  that  its  disad- 
vantages cannot  for  a  moment  be  weighed  against  those  attending 
protraction  and  its  consequences.  Against  this  conclusion  statistics 
may  possibly  be  quoted,  such  as  those  of  Churchill,  who  estimated 
that  1  in  20  mothers  delivered  by  forceps  in  British  practice  were 
lost.  But  the  fallacy  of  such  figures  is  apparent  on  the  slightest 
consideration  ;  and  by  no  one  has  this  been  more  conclusively  shown 
than  by  Drs.  Hicks  and  Phillips  in  their  paper  on  tables  of  mortality 
after  obstetric  operations,^  where  it  is  proved  in  the  clearest  manner 
that  such  results  are  due  not  to  the  treatment,  but  rather  to  the  fact 
that  the  treatmeiit  was  so  long  delayed. 

Iif)ipossihility  of  giving  Definite  Rules  for  use  of  Forceps. — It  is 
quite  impossible  to  lay  down  any  precise  rule  as  to  when  the  forceps 
should  be  used  in  uterine  inertia.  Each  case  must  be  treated  on  its 
own  merits,  and  after  a  careful  estimate  of  the  effect  of  the  pains. 
The  rules  generally  taught  were,  that  the  head  should  be  allowed  to 
rest  at  or  near  the  perineum  for  a  number  of  hours,  and  that  inter- 
ference was  contra-indicated  if  the  slightest  progress  were  being 
made.  It  is  needless  to  say  that  both  of  these  rules  are  incompatible 
with  the  views  I  have  been  inculcating,  and  that  any  rule  based  upon 
the  length  of  time  the  second  stage  of  labor  has  lasted  must  neces- 
sarily be  misleading.  AVhat  has  to  be  done,  I  conceive,  is  to  watch 
the  progress  of  the  case  anxiously  after  the  second  stage  has  fairly 
commenced,  and  to  be  guided  by  an  estimate  of  the  advance  that  is 
being  made  and  the  character  of  the  pains,  bearing  in  mind  that  the 
risk  to  the  mother,  and  still  more  to  the  child,  increases  seriously 
with  each  hour  that  elapses.  If  we  find  the  progress  slow  and  un- 
satisfactory, the  pains  flagging  and  insufficient,  and  incapable  of 
being  intensified  by  the  means  indicated,  then,  provided  the  head  be 
low  in  the  pelvis,  it  is  better  to  assist  at  once  by  the  forceps,  rather 
than  to  wait  until  we  are  driven  to  do  so  by  the  state  of  the  pa- 
tient.^ 

'  Obst.  Trans,  vol.  xiii. 

2  It  may,  perhaps,  be  of  interest  in  connection  with  this  important  topic  in  prac- 
tical midwifery,  if  I  reprint  a  letter  I  published  some  years  ago  in  the  Medical  Times 
and  Gazette.  An  historical  case,  such  as  tliat  of  which  it  treats,  will  better  illus- 
trate tlie  evil  effects  that  may  follow  unnecessary  delay  than  any  amount  of  argument. 
It  seems  to  me  impossible  to  read  the  details  of  the  delivery  it  describes  without 
being  forcibly  strucli  with  the  disastrous  results  which  followed  the  practice  adopted. 


344:  LABOR. 

Precipitate  Labor  less  common  than  Lingering. — Undue  rapidity  of 
labor  is  certainly  more  uncommon  than  its  converse,  but  still  it  is  by 

which,  however,  was  strictly  in  accordance  with  that  which,  up  to  a  quite  recent  date, 
has  been  considered  correct  by  tlie  higliest  obstetric  autliorities. 

ON  THE  DEATH  OF  THE  PRINCESS  CHARLOTTE  OF  WALES. 

(To  the  Editor  of  the  Medical  Times  and  Gazette.) 

Sir:  The  letter  of  your  correspondent,  "An  Old  Accoucheur,"  regarding  the 
death  of  the  Princess  Charlotte,  raises  a  question  of  great  interest — viz.,  whether 
the  fatal  result  might  have  been  averted  under  other  treatment  ?  The  history  of  the 
case  is  most  instructive,  and  I  think  a  careful  consideration  of  it  leaves  little  I'oom  to 
doubt  that,  though  the  management  of  the  labor  was  quite  in  accordance  with  the 
teaching  of  the  day,  it  was  entirely  opposed  to  that  of  modern  obstetric  science. 
The  following  account  of  the  labor  may  interest  your  readers  and  will  probably  be 
new  to  most  of  them.  It  is  contained  in  a  letter  from  Dr.  John  Sims  to  the  late  Dr. 
-Joseph  Clarke,  of  Dublin  : — 

London,  Novembei'  15,  1817. 

"My  Dear  Sir. — I  do  not  wonder  at  your  wishing  to  have  a  correct  statement  Oi 
the  labor  of  her  Royal  Highiiess  the  Princess  Charlotte,  the  fatal  issue  of  which  has 
involved  the  whole  nation  in  distress.  You  must  excuse  my  being  very  concise,  as  I 
have  been  and  am  very  much  hurried.  I  take  the  opportunity  of  writing  this  in  a 
lying-in  chamber.  Her  Royal  Highness's  labor  commenced  by  the  discharge  of  the 
liquor  amnii  about  seven  o'clock  on  Monday  evening,  and  the  pains  followed  soon 
after.  They  continued  through  the  night  and  a  greater  part  of  the  next  day — sharp, 
soft,  but  very  ineffectual.  Towards  the  evening  Sir  Richard  Croft  began  to  suspect 
that  labor  might  not  terminate  without  artificial  assistance,  and  a  message  was  des- 
patched for  me.  I  arrived  at  two  on  Wednesday  morning.  The  labor  was  now 
advancing  more  favorably,  and  both  Dr.  Baillie  and  myself  concurred  in  the  oiainion 
that  it  would  not  be  advisable  to  inform  her  Royal  Highness  of  my  arrival.  From 
this  time  to  the  end  of  her  labor  the  progress  was  uniform,  though  very  slow,  the 
patient  in  good  spirits,  the  pulse  calm,  and  there  never  was  room  to  entertain  a  ques- 
tion about  the  use  of  instruments.  About  six  in  the  afternoon  the  discharge  became 
of  a  green  color,  which  led  to  a  suspicion  that  the  child  might  be  dead  ;  still  the 
giving  assistance  was  quite  out  of  the  question,  as  the  pains  now  became  more 
effectual,  and  the  labor  proceeded  regularly  though  slowly.  The  child  was  born 
without  artificial  assistance  at  nine  o'clock  in  the  evening.  Attempts  were  made  for 
a  good  while  to  reanimate  it  by  inflating  the  lungs,  friction,  hot  baths,  etc.,  but  with- 
out effect  ;  the  heart  could  not  be  made  to  beat  even  once.  Soon  after  delivery  Sir 
Richard  Croft  discovered  that  the  uterus  was  contracted  in  the  middle  in  the  hour- 
glass form,  and  as  some  hemorrhage  commenced  it  was  agreed  that  the  placenta 
should  be  brought  away  by  introducing  the  hand.  This  was  done  about  half  an  hour 
after  the  delivery  of  the  child  with  more  ease  and  less  loss  of  blood  than  usual.  Her 
Royal  Highness  continued  well  for  about  two  hours  ;  she  then  complained  of  being 
sick  at  stomach,  and  of  noise  in  the  ears,  began  to  be  talkative,  and  her  jjulse  became 
frequent  ;  but  I  understand  she  was  very  quiet  after  this,  and  her  pulse  calm.  About 
half-past  twelve  o'clock  she  complained  of  severe  pain  in  her  chest,  became  ex- 
tremely restless,  with  rapid,  weak,  and  irregular  pulse.  At  this  time  I  saw  her  for 
the  first  time.  It  has  been  said  that  we  had  all  gone  to  bed,  but  that  is  not  a  fact ; 
Croft  did  not  leave  her  room,  Baillie  retired  about  eleven,  and  I  went  to  my  bed- 
chamber and  laid  down  in  my  clothes  at  twelve.  By  dissection,  some  bloody  fluid 
(two  ounces)  was  found  in  the  pericardium,  supposed  to  be  thrown  out  in  articulo 
mortis.  The  brain  and  other  organs  all  sound,  except  the  right  ovarium,  which  was 
distended  into  a  cyst  the  size  of  a  hen's  egg.  The  hour-glass  contraction  of  the 
uterus  still  visible, "and  a  considerable  quantity  of  blood  in  the  cavity  of  the  uterus — 
but  those  present  dispute  about  the  quantity,  so  much  as  from  twelve  ounces  to  a 
pound  and  a  half — her  uterus  extending  as  high  as  her  navel.  The  cause  of  her 
Royal  Highness's  death  is  certainly  somewhat  obscure  ;  the  symptoms  were  such  as 
attend  death  from  hemorrhage,  but  the  loss  of  blood  did  not  seem  to  be  sufficient  to 
account  for  a  fatal  issue.  It  is  possible  that  the  effusion  into  the  pericardium  took 
place  earlier  than  was  supposed,  and  it  does  not  seem  to  be  quite  certain  that  this 
might  not  be  the  cause.     That  I  did  not  see  her  Royal  Highness  more  early  was 


PROLONGED  AND  PRECIPITATE  LABORS.  345 

no  means  of  unfrequent  occurrence.  Most  obstetric  works  contain  a 
formidable  catalogue  of  evils  that  may  attend  it,  such  as  rupture  of 
the  cervix,  or  even  of  the  uterus  itself,  from  the  violence  of  the 
uterine  action;  laceration  of  the  perineum  from  the  presenting  part 
being  driven  through  before  dilatation  has  occurred  ;  fainting  from 
the  sudden  emptying  of  the  uterus;  hemorrhage  from  the  same  cause. 
With  regard  to  the  child  it  is  held  that  the  pressure  to  which  it  is 
subjected,  and  sudden  expulsion  while  the  mother  is  in  the  erect 
position,  may  prove  injurious.     Without  denying  that  these  results 

awkward,  and  it  would  have  been  better  that  I  had  been  introduced  before  the  labor 
was  expected  ;  and  it  should  have  l)een  understood  that  when  labor  came  on  I  should 
be  sent  to  without  waiting  to  know  whether  a  consultation  was  necessary  or  not.  I 
thought  so  at  the  time,  but  I  could  not  i)ropose  such  an  arrangement  to  Croft.  But 
tliis  is  entirely  entre  nous.  I  am  glad  to  hear  that  your  son  is  well,  and,  with  all  my 
family,  wish  to  be  remembered  to  him.  We  were  happy  to  liear  that  he  was  agree- 
ably married.  "  I  remain,  my  dear  Doctor, 

"  Ever  yours  most  truly, 

"  John  Sims,  M.D. 

"  This  letter  is  confidential,  as  perhaps  I  might  be  blamed  for  writing  any  particu- 
lars without  the  permission  of  Prince  Leopold." 

Wliat  are  the  facts  here  shown  ?  Here  was  a  delicate  young  woman  prepared  for 
the  trial  before  her,  as  Baron  Stockmar  tells  us,  by  "lowering  the  organic  strength 
of  the  mother  by  bleeding,  aperients,  and  low  diet,"  who  was  allowed  to  go  on  in 
lingering  feeble  labor  for  no  less  than  fifty-two  hours  after  the  escape  of  the  liquor 
amnii  !  Such  was  the  groundless  dread  of  instrumental  interference  then  j^revalent 
that,  although  the  case  dragged  on  its  weary  length  with  feeble  ineffectual  pains, 
every  now  and  then  increasing  a  little  in  intensity  and  then  falling  olf  again,  it  is 
stated  "  there  never  was  room  to  entertain  a  question  about  the  use  of  instruments  ;" 
and  even  "  when  the  discharge  became  of  a  green  color  .  .  .  still  the  giving  assist- 
ance was  quite  out  of  the  question!"  Can  any  reasonable  man  doubt  that  if  the 
forceps  had  been  employed  hours  and  hours  before — say  on  Tuesday,  when  the  pains 
fell  off — the  result  would  probably  have  been  very  different,  and  that  the  life  of  the 
child,  destroyed  by  the  enormously  prolonged  second  stage,  would  have  been  saved  ? 
It  must  be  remembered  that  early  on  Tuesday  morning  delivery  was  expected,  so 
that  the  head  must  then  have  been  low  in  the  pelvis  {vide  Stoclsmar's  "Memoirs," 
vol.  i.  p.  63).  It  would  be  difficult  to  find  a  case  which  more  forcibly  illustrates  tlie 
danger  of  delay  in  the  second  stage  of  labor.  Then  what  follows  ?  The  uterus, 
exhausted  by  the  lengthy  efforts  it  should  have  been  spared,  fails  to  contract  effect- 
ually; nor  do  we  hear  of  any  attempts  to  produce  contraction  by  pressure.  The 
relaxed  organ  becomes  full  of  clots,  extending  up  to  the  umbilicus,  and  all  the  most 
characteristic  symptoms  of  concealed  post-piartum  hemorrhage  develop  themselves. 
She  complained  "of  being  sick  at  stomach,  and  of  noise  in  her  ears — began  to  be 
talkative,  and  her  pulse  became  frequent."  Before  long  other  symptoms  came  on, 
graphically  described  by  Baron  Stockmar,  and  which  seem  to  point  to  the  formation 
of  a  clot  in  the  heart  and  pulmonary  arteries — a  most  likely  occurrence  after  such  a 
history.  "  Baillie  sent  me  word  that  he  wished  me  to  seethe  Princess.  I  hesitated, 
but  at  last  went  with  him.  She  was  sufi"ering  from  spasms  of  the  chest  and  diffi>julty 
of  breathing,  in  great  pain,  and  very  restless,  and  threw  herself  continually  from  one 
side  of  the  bed  to  the  other,  speaking  now  to  Baillie,  now  to  Croft.  Baillie  said  to  her 
— '  Here  comes  aii  old  friend  of  yours.'  She  held  out  her  left  hand  to  me,  hastily,  and 
pressed  mine  warmly  twice.  I  felt  her  pulse  ;  it  was  going  very  fast — the  beats  now 
strong,  now  feeble,  now  intermittent." 

Here  was  evidently  something  diiferent  from  the  exhaustion  of  hemorrhage  ;  and 
no  one  who  has  witnessed  a  case  of  pulmonary  obstruction  can  fail  to  recognize  in  this 
account  an  accurate  delineation  of  its  dreadful  symptoms. 

Surely  this  lamentable  story  can  only  lead  to  the  conclusion  that  the  unhappy  and 
gifted  Princess  fell  a  victim  to  the  dread  of  that  bugbear,  "  meddlesome  midwifery," 
which  has  so  long  retarded  the  i^rogress  of  obstetrics. 

I  am,  etc.,  W.  S.  Playfaik. 

Curzoa-street,  Mayfair,  W.,  November  29,  1872. 
23 


346  LABOR. 

may  possibly  occur  now  and  again,  in  tlie  majority  of  cases  over-rapid 
labor  is  not  attended  with  any  evil  effects. 

Precipitate  labor  may  generally  be  traced  to  one  of  two  conditions, 
or  to  a  combination  of  both  ;  excessive  force  and  rapidity  of  the 
pains,  or  unusual  laxity  and  want  of  resistance  of  the  soft  parts. 
The  precise  causes  inducing  these  it  is  difficult  to  estimate.  In  some 
cases  the  former  may  depend  on  an  undue  amount  of  nervous  excita- 
bility, and  the  latter  on  the  constitutional  state  of  the  patient  tend- 
ing to  relaxation  of  the  tissues. 

Whatever  the  cause,  the  extreme  rapidity  of  labor  is  occasionally 
remarkable,  and  one  strong  pain  may  be  sufficient  to  effect  the  ex- 
pulsion of  the  child,  with  little  or  no  preliminary  warning.  I  have 
known  a  child  to  be  expelled  into  the  pan  of  a  water-closet,  the  only 
previous  indication  of  commencing  labor  being  a  slight  griping  pain 
which  led  the  mother  to  fancy  that  an  action  of  the  bowels  was  about 
to  take  place.  More  often  there  is  what  may  be  described  as  a 
storm  of  uterine  contractions,  one  pain  following  the  other  with  great 
intensity,  until  the  foetus  is  expelled.  The  natural  effect  of  this 
is  to  produce  a  great  amount  of  alarm  or  nervous  excitement,  which 
of  itself  forms  one  of  the  worst  results  of  this  class  of  labor.  It  is 
under  such  circumstances  that  temporary  mania  occurs,  produced  by 
the  intensity  of  the  suffering,  under  which  the  patietit  may  commit 
acts  her  responsibility  for  which  may  fairly  be  open  to  question. 

Treatment. — -Little  can  be  done  in  treating  undue  rapidity  of  labor. 
We  can,  to  some  extent,  modify  the  intensity  of  the  pains  by  urging 
the  patient  to  refrain  from  voluntary  efforts,  and  to  open  the  glottis 
by  crying  out,  so  that  the  chest  may  no  longer  be  a  fixed  point  for 
muscular  action.  Opiates  have  been  advised  to  control  uterine 
action,  but  it  is  needless  to  point  out  that,  in  most  cases,  there  is  no 
time  for  them  to  take  effect.  Chloroform  will  often  be  found  most 
valuable,  from  the  rapidity  with  which  it  can  be  exhibited ;  and  its 
power  of  diminishing  uterine  action,  which  forms  one  of  its  chief 
drawbacks  in  ordinary  practice,  will  here  prove  of  much  service. 


CHAPTER    X. 

LABOR    OBSTRUCTED    BY    FAULTY    CONDITION    OF    THE    SOFT   PARTS. 

Rigidity  of  the  Cervix  a  frequent  Cause  of  Protracted  Labor. — One 
of  the  most  frequent  causes  of  delay  in  the  first  stage  of  labor  is 
rigidity  of  the  cervix  uteri,  which  may  depend  on  a  variety  of  con- 
ditions. It  is  often  produced  by  premature  escape  of  the  liquor 
amnii,  in  consequence  of  which  the  fluid  w^edge,  which  is  nature's 
means  of  dilating  the  os,  is  destroyed  and  the  hard  presenting  part 


OBSTRUCTION    FROM    CONDITION    OF    SOFT    PARTS,  347 

is  consequently  brought  to  bear  directly  upon  the  tissues  of  the  cer- 
vix, which  are  thus  unduly  irritated,  and  thrown  into  a  state  of 
spasmodic  contraction.  At  other  times  it  may  be  due  to  consti- 
tutional peculiarities,  among  which  there  is  ncnie  so  common  as  a 
highly  nervous  and  emotional  temperament,  which  renders  the  patient 
peculiarly  sensitive  to  her  sulferivigs,  and  interferes  with  the  har- 
monious action  of  the  uterine  fibres.  The  pains,  in  such  cases,  cause 
intense  agony,  are  short  and  cramp-like  in  character,  but  have  little 
or  no  effect  in  |)roducing  dilatation  ;  the  os  often  remaining  for  many 
hours  without  any  appreciable  alteration,  its  edges  being  thin  and 
tightly  stretched  over  the  head.  Less  often,  and  this  is  generally 
met  with  in  stout  plethoric  women,  the  edges  of  the  os  are  thick 
and  tough. 

Effects. — The  effects  of  prolongation  of  labor  from  this  cause  will 
vary  much  under  different  circumstances.  If  the  liquor  ainnii  be 
prematurely  evacuated,  the  presenting  part  presses  directly  upon  the 
cervix,  and  the  case  is  then  practically  the  same  as  if  the  labor  were 
in  the  second  stage.  Hence  grave  symptoms  may  soon  develop  them- 
selves, and  early  interference  may  be  imperatively  demanded.  If  the 
membranes  be  unruptured,  delay  will  be  of  comparatively  little 
moment,  and  considerable  time  may  elapse  without  serious  detriment 
to  either  the  mother  or  child. 

Treatment. — The  treatment  will  naturally  vary  much  with  the 
cause,  and  the  state  of  the  })atient.  In  the  majority  of  cases,  espe- 
cially if  the  membranes  be  still  intact,  patience  and  time  are  sufficient 
to  overcome  the  obstacle ;  but  it  is  often  in  the  power  of  the  ac- 
coucheur materially  to  aid  dilatation  by  appropriate  management. 
Sometimes  nature  overcomes  the  obstruction  by  lacerating  the  oppos- 
ing structures,  and  cases  are  on  record  in  which  even  a  complete 
ring  of  the  cervix  has  been  torn  off",  and  come  away  before  the  head. 

Many  remedies  have  been  recommended  for  facilitating  dilatation, 
some  of  which  no  doubt  act  beneficially.  Among  those  most  fre- 
quently resorted  to  was  venesection,  and  with  it  was  generally 
associated  the  administration  of  nauseating  doses  of  tartar  emetic. 
Both  these  acted  by  producing  temporary  depression,  binder  which 
the  resistance  of  the  soft  part  was  lessened.  They  probably  answered 
best  in  cases  in  which  there  was  a  rigid  and  tough  cervix ;  and  they 
might  prove  serviceable,  even  yet,  in  stout  plethoric  women  of  robust 
frame.  Practically  they  are  now  seldom,  if  ever,  employed,  and 
other  and  less  debilitating  remedies  are  preferred.  The  agent,  par 
excellence^  which  is  most  serviceable  is  chloi'al,  which  is  of  special 
value  in  the  more  common  cases  in  which  rigidity  is  associated  with 
spasmodic  contraction  of  the  muscular  fibres  of  the  cervix.  Two  to 
three  doses  of  15  grains,  reyjeated  at  intervals  of  twenty  minutes,  are 
often  of  almost  magical  efficacy,  the  pains  becoming  steady  and 
regular,  and  the  os  gradually  relaxing  sufficiently  to  allow  the  passage 
of  the  head.  Chloroform  acts  much  in  the  same  way,  but  on  the 
whole  less  satisfactorily,  its  effects  being  often  too  great ;  while  the 
peculiar  value  of  chloral  is  its  influence  in  promoting  relaxation  of 
the  tissues,  without  interfering  with  the  strength  of  the  pains. 


348  LABOR. 

Local  Means  of  Treatment. — Yarious  local  means  of  treatment  may 
be  also  advantageously  used.  One  is  the  warm  bath,  which  is  much 
used  in  France.  It  is  of  unquestionable  value  where  there  is  much 
rigidity,  and  may  be  used  either  as  an  entire  bath,  or  as  a  hip  bath,  in 
which  the  patient  sits  from  twenty  minutes  to  half  an  hour.  The  ob- 
jection is  the  fuss  and  excitement  it  causes,  and,  for  this  reason,  it  is 
an  expedient  seldom  resorted  to  in  this  country.  A  similar  effect  is 
produced,  and  much  more  easily,  by  a  douche  of  tepid  water  upon  the 
cervix.  This  can  be  very  easily  administered,  the  pipe  of  a  Higgin- 
son's  syriuge  being  guided  up  to  the  cervix  by  the  index  finger  of 
the  right  hand,  and  a  stream  of  Avater  projected  against  it  for  five 
or  ten  minutes.  Smearing  the  os  with  exti'act  of  belladonna  is  ad- 
vised by  Continental  authorities,  but  its  effects  are  more  than  doubt- 
ful. Horton^  advocates  the  injection  into  the  tissue  of  the  cervix  of 
■j'o  of  a  grain  of  atropine  by  means  of  a  hypodermic  syringe,  and 
speaks  very  favorably  of  the  practice. 

Artificial  dilatation  of  the  cervix  by  the  finger  has  often  been  rec- 
ommended, and  has  been  the  subject  of  much  discussion,  especially 
in  the  Edinburgh  school,  where  it  was  formerly  commonly  employed. 
It  is  capable  of  being  very  useful,  but  it  may  also  do  much  injury 
when  roughly  and  injudiciously  used.  The  class  of  cases  in  which 
it  is  most  serviceable  are  those  in  which  the  liquor  amnii  has  been 
long  evacuated,  and  in  which  the  head,  covered  by  the  tightly 
stretched  cervix,  has  descended  low  into  the  pelvic  cavity.  Under 
these  circumstances,  if  the  finger  be  passed  gently  within  the  os 
during  a  pain,  and  its  margin  pressed  upwards  and  over  the  head 
as  it  were,  while  the  contraction  lasts,  the  progress  of  the  case  may  be 
materially  facilitated.  This  manoeuvre  is  somewhat  similar  to  that 
which  has  been  already  spoken  of,  when  the  anterior  lip  of  the  cervix 
is  caught  between  the  head  and  the  pubic  bone,  and,  if  properly  per- 
formed, I  believe  it  to  be  quite  safe,  and  often  of  great  value.  It  is 
not,  however,  well  adapted  for  those  cases  in  which  the  membranes  are 
still  intact,  or  in  which  the  os  remains  undilated  when  the  head  is 
still  high  in  the  pelvis.  When  there  is  much  delay  under  these  condi- 
tions, and  interference  of  some  kind  seems  called  for,  the  dilatation 
may  be  much  assisted  by  the  use  of  caoutchouc  dilators,  described 
in  the  chapter  on  the  induction  of  premature  labor,  which  imitate 
nature's  method  of  opening  up  the  os,  and  [ilso  act  as  a  direct  stimu- 
lant to  uterine  contraction.  But  it  should  be  remembered,  that  it  is 
precisely  in  such  cases  that  delay  is  least  prejudicial.  If,  however, 
the  OS  be  excessively  long  in  opening,  its  dilatation  maj  be  safely 
and  efficiently  promoted  by  passing  within  it,  and  distending  with 
water,  one  of  the  smallest  sized  bags ;  and,  after  this  has  been  in 
position  from  ten  to  twenty  minutes,  it  may  be  removed,  and  a  larger 
one  substituted. 

Rigidity  depending  upon  Organic  Causes. — Every  now  and  again 
we  meet  with  cases  in  which  the  obstacle  depends  upon  organic 
chano;es  in  the  cervix,  the  most  common  of  which  are  cicatricial 

'  Amer.  Journ.  of  Obst.  July,  1878. 


OBSTRUCTION    FROM    CONDITION    OF    SOFT    PARTS.  349 

hardening  from,  former  lacerations ;  hypertrophic  elongation  of  the 
cervix  from  disease  antecedent  to  pregnancy ;  or  even  agglutination 
and  closure  of  the  os  uteri.  Cicatrices  are  generally  the  result  of 
lacerations  during  former  labors.  They  implicate  a  portion  onlj^  of 
the  cervix,  which  they  render  hard,  rigid,  and  undilatable,  while  the 
remainder  has  its  natural  softness.  Tiicy  can  readily  be  made  out 
by  the  examining  finger,  A  somewhat  similar,  but  much  more  for- 
midable, obstruction  is  occasionally  met  with  in  cases  of  old-standing 
hypertrophic  elongation  of  the  cervix,  which  is  generally  associated 
with  prolapse.  In  most  cases  of  this  kind  the  cervix  becomes  soft- 
ened during  pregnancy,  so  that  dilatation  occurs  without  any  un- 
usual difficulty.  But  this  does  not  always  happen.  A  good  ex- 
ample is  related  by  Mr.  Roper,  in  the  seventh  volume  of  the  "  Ob- 
stetrical Transactions,"  in  which  such  a  cervix  formed  an  almost 
insuperable  obstacle  to  the  passage  of  the  child. 

Carcinoma  of  the  cervix  uteri,  which  produces  extensive  thicken- 
ing and  induration  of  its  tissues,  and  even  advanced  malignant  dis- 
ease of  the  uterus  is  no  bar  to  conception.  The  relations  of  malignant 
disease  to  pregnancy  and  parturition  have  recently  been  well  studied 
by  Dr.  Herman.^  lie  concludes  that  cancer  renders  the  patient  inapt 
to  conceive,  but  that  when  pregnancy  does  occur  there  is  a  tendency 
to  the  intra-uterine  death  and  premature  exj^ulsion  of  the  foetus,  and 
the  growth  of  the  cancer  is  accelerated.  AYhen  delivery  is  accom- 
plished naturally  there  is  generally  expansion  of  the  cervix  toy  Assuring 
of  its  tissue,  but  the  harder  forms  of  cancer  may  form  an  insuperable 
obstacle  to  delivery. 

Occlusion  of  the  Os. — Agglutination  of  the  margins  of  the  os  uteri 
is  occasionally  met  with,  and  must,  of  course,  have  occurred  after 
conception.  It  is  generally  the  result  of  some  inflammatory  affec- 
tion of  the  cervix  during  the  early  months  of  gestation,  and  I  have 
known  it  recur  in  the  same  woman  in  two  successive  pregnancies. 
Usually  it  is  not  associated  with  any  hardness  or  rigidity,  but  the 
entire  cervix  is  stretched  over  the  presenting  part,  and  forms  a 
smooth  covering,  in  which  the  os  may  only  exist  as  a  small  dimple, 
and  may  be  very  dif&cult  to  detect  at  all.  Occlusion  of  the  os  uteri 
from  inflammatory  change,  sometimes  so  alters  the  cervix,  that  no 
sign  of  the  original  opening  can  be  discovered ;  and  in  two  such  in- 
stances, the  Ctesarean  operation  has  been  jDcrformed  in  the  United 
States,  by  which  the  women  were  saved.^ 

Their  Treatment. — Any  of  these  mechanical  causes  of  rigidity  may 
at  first  be  treated  in  the  same  way  as  the  more  simple  cases ;  and 
with  patience,  the  use  of  chloral  and  chloroform,  and  of  the  fluid 
dilators,  sufficient  expansion  to  permit  the  passage  of  the  head  will 
often  take  place.  But  if  these  methods  produce  no  effect,  and  sjaup- 
toms  of  constitutional  irritation  are  beginning  to  develop  themselves, 
other,  and  more  radical,  means  of  overcoming  the  obstruction  may 
be  required. 

'  Obstet.  Trans.,  vol.  xx.  p.  191. 

2  Harris's  note  to  second  American  edition. 


350  LABOR. 

Incision  of  the  Cervix. — Under  such  circumstances  incision  of  tlie 
cervix  may  be  not  only  justifiable  bat  essential,  and  it  frequently 
answers  extremely  well.  On  the  Continent  it  is  resorted  to  much 
more  frequently  and  earlier  than  in  this  country,  and  with  the  most 
beneficial  results.  The  operation  ofi'ers  no  difiiculties.  The  simplest 
way  of  performing  it  is  to  guard  the  greater  portion  of  the  blade  of 
a  straight  blunt-pointed  bistoury  by  wrapping  lint  or  adhesive  plas- 
ter round  it,  leaving  about  half  an  inch  cutting  edge  towards  its 
point.  This  is  guided  to  the  cervix,  on  the  under  surface  of  the 
index  finger,  and  three  or  four  notches  are  cut  in  the  circumference 
of  the  OS  to  about  the  depth  of  a  quarter  of  an  inch.  Yerj  gener- 
ally, especially  when  the  obstruction  is  only  due  to  old  cicatrices,  the 
pains  will  now  speedily  effect  complete  expansion,  which  may 
be  very  advantageously  aided  by  applying  the  hydrostatic  dilators. 
When  the  obstruction  is  due  to  carcinomatous  iniiltration  or  inflam- 
matory thickening,  the  case  is  much  more  complicated,  and  will 
painfully  tax  the  resources  of  the  accoucheur.  If  it  is  possible  the 
disease  should  be  removed  as  much  as  can  be  safely  done  during 
pregnancy,  which  should  also  be  brought  to  an  end  before  the  full 
period.  During  labor  incisions  should  form  a  preliminary  to  any  sub- 
sequent proceedings  that  may  be  necessary,  as  tbey  are,  at  the  worst, 
not  likely  to  increase  in  the  least  the  risks  the  patient  has  to  run,  and 
they  may  possibly  avert  more  serious  operations.  In  the  case  of 
malignant  disease  the  risk  of  serious  hemorrhage,  from  the  great 
vascularity  of  the  tissues,  must  not  be  forgotten,  and,  if  necessary, 
means  must  be  taken  to  check  this  by  local  styptics,  such  as  per- 
chloride  of  iron.  If  incision  fail,  and  the  state  of  the  patient  de- 
mands speedy  delivery,  the  forceps  may  be  applied,  and  Herman 
thinks  they  are,  as  a  rule,  better  than  turning.  He  also  maintains  that 
there  is  little  difference  in  the  risk  to  the  mothers  between  craniotomy 
and  the  Csesarean  section,  and  that  the  possibility  of  saving  the  child 
in  cases  in  which  incisions  have  failed,  should  induce  us  to  prefer  the 
latter. 

Application  of  the  Forceps  v:ithin  the  Cervix. — Before  performing 
craniotomy,  when  the  os  is  sufficiently  open,  a  cautious  application 
of  the  forceps  is  quite  justifiable.  Steady  and  careful  downward 
traction,  combined  with  digital  expansion,  has  often  enabled  a  head 
to  pass  with  safety  through  an  os  that  has  resisted  all  other  means 
of  dilatation,  and  the  destruction  of  the  child  has  thus  been  avoided. 
If,  indeed,  the  os  appear  to  be  dilatable,  this  procedure  may  advan- 
tageously be  adopted  before  incision,  and,  as  a  matter  of  fact,  it  is 
commonly  practised  in  the  Eotunda  Hospital.  An  operation  involv- 
ing, beyond  doubt,  of  itself  some  risk,  and  requiring  considerable 
operative  dexterity,  would  naturally  not  be  lightly  and  inconsider- 
ately undertaken.  But  when  it  is  remembered  that  the  alternative 
is  the  destruction  of  the  child,  the  risk  of  exhaustion,  and  at  least 
as  great  mechanical  injury  to  the  mother,  its  difficulty  need  not  stand 
in  the  way  of  its  adoption. 

Treatment  when  Occlusion  of  the  Os  Exists. —  When  the  os  is  appa- 
rently obliterated,  incision  is  the  only  resource.     Before  resorting  to 


OBSTRUCTION    FROM    CONDITION    OF    SOFT    PARTS.  351 

it  the  patient  should  be  placed  under  chloroform,  and  the  entire  lower 
segment  of  the  uterus  carefallj  explored.  Possibly  the  aperture 
may  be  found  high  up,  and  out  of  reach  of  an  ordinary  examination, 
or  we  may  detect  a  depression  corresponding  to  its  site._  A  small 
crucial  incision  may  then  be  made  at  the  site  of  the  os,  if  this  can 
be  ascertained;  if  not  at  the  most  prominent  portion  of  the  cervix. 
Yery  generally  the  pains  will  then  suffice  to  complete  expansion, 
which  may  be  further  aided  by  the  fluid  dilators. 

Anle-partum  Hour-glass  Contraction} — Dr.  liosmer^  has  recently 
drawn  attention  to  a  hitherto  undescribed  species  of  dystocia,  which 
he  terms  "  ante-partum  hour-glass  contraction''  and  which  he  believes 
to  depend  on  constriction  of  the  uterine  fibres  at  the  site  of  the 
internal  os  uteri.  Harris^  doubts  its  limitation  to  the  internal  os 
uteri,  and  terms  it  "  tetanoid  falciform  constriction  of  the  uterus." 
Whatever  its  site  in  the  cases  recorded,  difficulties  of  the  most  for- 
midable kind  come  from  this  cause.  The  pelves  were  normal  and  the 
presentations  natural,  yet  out  of  seven  labors,  four  ended  fatally,  two 
before  delivery.  The' constriction  seems  to  have  grasped  the  foetus 
with  such  force  as  to  have  rendered  extraction,  either  by  the  forceps 
or  turning,  impossible.  I  have  no  personal  experience  of  this  com- 
plication, which  must  fortunately  be  very  rare.  The  introduction 
of  the  hand,  the  patient  being  deeply  anaesthetized,  would  probably 
render  diagnosis  easy.  The  treatment  must  depend  on  the  force 
and  amount  of  constriction.  If  the  constriction  does  not  relax  under 
chloroform,  chloral,  or  the  injection  of  atropine  into  the  site  of  con- 
striction, as  recommended  by  Horton  in' rigidity  of  the  cervix,  turn- 
ing would  probably  be  our  best  resource.  Should  this  fail,  the 
CcBsarean  section  may  be  required  to  effect  delivery.  Gastro-ely- 
trotomy  is  obviously  unsuitable  for  such  cases. 

Bands  and  Cicatrices  in  the  Vagina.  —  Extreme  rigidity  of  the 
vagina,  or  bands  and  cicatrices  in  or  across  its  walls,  the  result  of 
congenital  malformation,  of  injuries  in  former  labors,  or  of  antece- 

['  Since  the  article  by  Dr.  Hosmer  appeared,  attention  has  been  drawn  to  fully  as 
many  more  cases  in  the  United  States  ;  in  one  of  which  the  constriction  was  oblique. 
Long  perseverance  with  anaesthesia  appears  to  have  met  with  success  in  overcoming 
the  tension  of  the  constricting  band,  which  in  one  instance  almost  severed  the  body 
of  the  foetus. 

Dr.  T.  A.  Foster,  of  Portland,  Maine,  has  met  with  two  cases,  on  one  of  which,  a 
primipara  of  40,  he  was  forced  to  perform  -the  Caesarean  section,  as  the  constriction 
was  complicated  with  eclampsia,  the  woman  having  advanced  Bright's  disease  ;  she 
survived  the  operation  only  sixty  hours.  In  a  recently  written  letter  he  says,  "  Be- 
fore opening  the  uterus,  it  presented  the  appearance  of  a  pregnant  womb,  constricted 
at  the  junction  of  the  lower  and  middle  third.  That  a  portion  of  the  body  of  the 
uterus  was  below  the  constriction  I  feel  very  sure.  The  child's  head  was  entirely 
below  it,  and  had  not  so  much  as  reached  the  external  os,  the  anterior  lip  of  which 
was  not  involved  to  any  great  extent  in  the  fibroid  growth. 

"  I  think  the  incision  abo^e  the  constriction  was  from  four  to  six  inches  long, 
reaching  from  the  fundus  to  the  constricted  part.  The  most  depressed  part  of  the 
constriction  was  very  narrow  and  cord-like.  Above  and  below,  the  muscular  stru'-- 
ture  seemed  to  be  so  disarranged  by  fibroids,  that  no  regular  constriction  took  place, 
while  a  portion  in  the  region  of  the  constriction,  some  three  inches  wide,  was  free 
from  fibroids,  and  seemed  to  act  powerfully  and  constantly." — Ed.] 

2  Boston  Med.  and  Surg.  .Tourn.,  March  and  May,  1878. 

3  Harris's  note  to  2d  American  edition. 


352  LABOK. 

dent  disease,  occasionally  obstruct  the  second  stage.  There  is  seldom 
any  really  formidable  difficulty  from  this  cause,  since  the  obstruction 
almost  always  yields  to  the  pressure  of  the  presenting  part.  If  there 
be  any  considerable  extent  of  cicatrices  in  the  vagina,  artificial  assist- 
ance may  be  required.  If  we  should  be  aware  of  their  existence 
during  pregnancy,  and  find  them  to  be  suifioiently  dense  and  ex- 
tensive to  be  likely  to  interfere  with  delivery,  an  endeavor  may  be 
made  to  dilate  them  gradually  by  hydrostatic  bags  or  bougies.  If 
they  be  not  detected  until  labor  is  in  progress,  we  must  be  guided  in 
our  procedures  by  the  pressure  to  which  they  are  subjected.  It  may 
then  be  necessary  to  divide  them  with  a  knife,  and  to  hasten  the 
passage  of  the  head  by  the  forceps,  so  as  to  prevent  contusion  as 
much  as  possible.  It  is  obviously  impossible  to  lay  down  any  posi- 
tive rules  for  such  rare  contingencies,  the  treatment  suitable  for  which 
must  necessarily  vary  much  with  the  individual  peculiarities  of  the  case. 

Extreme  rigidity  of  the  perineum  is  often  dependent  upon  cicatricial 
hardening  from  injury  in  previous  labors.  This  may  greatly  inter- 
fere with  its  dilatation;  and  if  laceration  seems  inevitable,  we  may  be 
quite  justified  in  attempting  to  avert  it  by  incision  of  the  margins  of 
the  perineum,  on  the  principle  of  a  clean  cut  being  always  preferable 
to  a  jagged  tear. 

Labor  Complicated  with  Tumor. — Occasionally  we  meet  with  very 
formidable  obstacles  from  tumors  connected  with  the  maternal  struc- 
tures. These  are  most  commonly  either  fibroid  or  ovarian,  although 
others  may  be  met  with,  such  as  malignant  growths  from  the  pelvic 
bones,  exostoses,  etc. 

Fibroid  Tumors  of  the  Uterus. — Considering  the  frequency  with 
which  women  suffer  from  fibroid  tumors  of  the  uterus,  it  is  perhaps 
somewhat  remarkable  that  they  do  not  more  often  comphcate  de- 
li verv.  Probably  women  so  affected  are  not  apt  to  conceive.  Occa- 
sionally, however,  cases  of  this  kind  cause  much  anxiety ._  Of  course, 
the  cases  are  most  grave  in  which  the  tumors  are  so  situated  as  to 
encroach  upon  the  cavity  of  the  pelvis,  and  mechanically  obstruct 
the  passage  of  the  child"^  Even  those  in  which  this  does  not  occur 
are  by  no°means  free  from  danger,  for  interstitial  and  sub-peritoneal 
fibroids,  situated  in  the  upper  parts  of  the  uterus,  and  leaving  the 
pelvic  cavity  quite  unimplicated,  may  interfere  with  the  action  of 
the  uterine  fibres,  prevent  subsequent  contraction,  cause  profuse  post- 
partum hemorrhage,  or  even  predispose  to  rupture  of  the  nterine 
tissue.  Hence,  every  case  in  which  the  existence  of  uterine  fibroids 
has  been  ascertained  m.ust  be  anxiously  watched.  The  risk  of  hemor- 
rhage is  perhaps  the  greatest;  for,  if  \he  tumors  be  at  all  large,  ei!i- 
cient  contraction  of  the  uterus  after  the  birth  of  the  child  must  be 
more  or  less  interfered  with.  Fortunately  it  is  not  so  common  as 
mi^ht  almost  be  expected.  Out  of  5  cases  recorded  in  the  "Obstet- 
rical Transactions,"  2  of  which  were  in  my  own  practice,  no  hemor- 
rhao-e  occurred  ;  nor  does  it  seem  to  have  happened  in  any  of  the  26 
cases  collected  by  Magdelaine  in  his  thesis  on  the  subject.  I  recently 
saw  an  interesting  example  of  tliis  in  a  patient,  whose  case  was 
looked  forward  to  with  much  anxiety,  in  consequence  of  the  exist- 


OBSTRUCTION    FROM    CONDITION    OF    SOFT    PARTS.  353 

ence  of  several  enormous  fibroid  masses  projecting  from  the  fundus 
and  anterior  surface  of  the  body  of  the  uterus,  and  whose  labor  was, 
nevertheless,  typically  normal  in  every  way.  Should  hemorrhage 
occur  after  delivery,  the  injection  of  styptic  solutions  would  probably 
be  peculiarly  valuable,  since  the  ordinary  means  of  promoting  con- 
traction are  likely  to  fail. 

It  is  when  the  fibroid  growths  implicate  the  lower  uterine  zone 
and  the  cervical  region,  that  the  greatest  difficulties  are  likely  to  be 
met  with.  The  practice  then  to  be  adopted  must  be  regulated  to  a 
great  extent  by  the  nature  of  each  individual  case.  If  it  be  possible 
to  push  the  tumor  above  the  pelvic  brim,  out  of  the  way  of  the  pre- 
senting part,  that,  no  doubt,  is  the  best  course  to  pursue,  as  not 
only  clearing  the  passage  in  the  most  effectual  way,  but  removing 
the  tumor  from  the  bruising  to  which  it  would  otherwise  be  subjected 
when  pressed  between  the  head  and  the  pelvic  walls,  Avhich  seems  to 
be  one  of  the  greatest  dangers  of  this  complication.  This  manoeuvre 
is  sometimes  possible  in  what  seem  to  be  the  most  unpromising 
circumstances.  An  interesting  example  is  narrated  by  Mr.  Spencer 
Wells,^  who,  called  to  perform  the  Cresarean  section,  succeeded, 
although  not  without  much  difficulty,  in  pushing  the  obstructing 
mass  above  the  brim,  the  child  subsequently  passing  with  ease.  I 
have  myself  elsewhere  recorded  two  similar  cases^  in  which  I  was 
enabled  to  deliver  the  patient  by  pushing  up  the  obstructing  tumor, 
in  both  of  which  the  C^esarean  section  would  have  been  inevitable  had 
the  attempt  at  reposition  failed.  Therefore,  before  resorting  to  more 
serious  operative  procedures,  a  determined  effort  at  pushing  the 
tumor  out  of  the  way  should  be  made,  the  patient  being  deeply 
chloroformed,  and,  if  necessary,  upward  pressure  being  made  by  the 
closed  fist  passed  into  the  vagina. 

Enucleation  or  Ablation. — Failing  this,  the  possibility  of  enucle- 
ating the  tumor,  or,  if  that  be  not  possible,  of  removing  it  piecemeal 
with  the  ecraseur,  should  be  considered.  On  account  of  the  loose 
attachments  of  these  growths,  and  the  facility  with  which  they  can 
be  removed  in  this  way  in  the  non-pregnant  state,  the  expedient  seems 
certainly  well  worthy  of  a  trial,  if  their  site  and  attachments  render 
it  at  all  feasible.  Interesting  examples  of  the  successful  performance 
of  this  operation  are  recorded  by  Danyau  and  Braxton  Hicks. 
Should  it  be  found  impracticable,  the  case  must  be  managed  in  refer- 
ence to  the  amount  of  obstruction  ;  and  the  forceps,  craniotomy,  or 
even  the  Ciiesarean  section,  may  be  necessary. 

[In  1874,  Dr.  Cornelius  Olcott,^  of  Brooklyn,  N.  Y.,  was  forced  to 
perform  the  Ca9sarean  section  in  a  case  where  a  fibroid  tumor  com- 
pletely filled  the  vagina.  The  tumor  was  pushed  up  and  forceps 
applied,  but  traction  at  once  caused  it  to  descend.  After  9|-  hours  of 
labor,  and  7|  of  efforts  to  deliver,  under  ether  and  chloroform,  the 
woman  being  much  exhausted,  the  operation  was  performed,  and  a 
dead  foetus  removed.     The  mother  lived  exactly  four  years,  dying 

1  Obst.  Trans.,  vol.  ix.  p.  73.  2  obst.  Trans.,  vol.  xix.  p.  101. 

[3  Am.  Journ.  Obstetrics,  N.  Y.,  April,  1879,  p.  312.] 


354 


LABOR. 


from  peritonitis  set  up  by  the  tumor,  on.  tlie  anniversary  of  her  ope- 
ration. The  growth  was  located  in  the  left  lateral  wall  of  the  uterus, 
extending  from  the  cervix  midway  to  the  fundus. — Ed.] 

Tumors  of  the  Ovaries. — The  next  most  common  class  of  obstruct- 
ing tumors  are  those  of  the  ovary  (Fig.  121),  and  it  is  apparently 
not  the  largest  of  these  which  are  most  apt  to  descend  into  the  pelvic 
cavity.     When  the  tumor  is  of  any  considerable  size,  its  bulk  is  such 

Fig.  121, 


Labor  Complicated  by  Ovarian  Tumor. 

that  it  cannot  be  contained  in  the  true  pelvis,  and  it  rises  into  the  ab- 
dominal cavity  with  the  uterus.  Hence,  the  existence  of  the  tumor 
that  offers  the  most  formidable  obstacle  to  delivery  is  rarely  suspected 
before  labor  sets  in. 

In  order  to  estimate  the  results  of  the  various  methods  of  treat- 
ment, I  have  tabulated  57  cases.^  In  18  labor  was  terminated  by 
the  natural  powers  alone ;  but  of  these  6  mothers,  or  nearly  one-half, 
died.  In  favorable  contrast  with  these  we  have  the  cases  in  which 
the  size  of  the  tumor  was  diminished  by  puncture.  These  are  9  in 
number,  in  all  of  which  the  mother  recovered  ;  6  out  of  the  9  chil- 
dren being  saved.  The  reason  of  the  great  mortality  in  the  former 
cases  is  apparently  the  bruising  to  which  the  tumor,  even  when  small 
enough  to  allow  the  child  to  be  squeezed  past  it,  is  necessarily  sub- 
jected. This  is  extremely  apt  to  set  up  a  fatal  form  of  diffuse  in- 
flammation, the  risk  of  which  was  long  ago  pointed  out  by  Ashwell,^ 
who  draws  a  comparison  between  cases  in  Avhich  such  tumors  have 
been  subjected  to  contusion  and  cases  of  strangulated  hernia ;  and 
the  cause  of  death  in  both  is  doubtless  very  similar.  Tliis  danger  is 
avoided  when  the  tumor  is  punctured,  so  as  to  become  flattened  be- 


'  Obst.  Trans,  vol.  ix. 


2  Guy's  Hospital  Reports,  vol.  ii. 


OBSTRUCTION    FROM    CONDITION    OF    SOFT    PARTS.  355 

tween  the  head  and  the  pelvic  walls.  On  this  account,  I  think,  it 
should  be  laid  down  as  a  rule  that  puncture  should  be  performed  in 
all  cases  of  ovarian  tumor  engaged  in  front  of  the  presenting  part, 
even  when  it  is  of  so  small  a  size  as  not  to  preclude  the  possibility  of 
delivery  by  the  natural  powers. 

Treatment  token  PmicLure  Fails. — In  5  of  the  57  cases  it  was  found 
possible  to  return  the  tumor  above  the  pelvic  brim,  and  in  these  also 
the  termination  was  very  favorable,  all  the  mothers  recovering. 
Should  puncture  not  succeed,  and  it  may  fail  on  account  of  the  gelati- 
nous and  semi-solid  nature  of  the  contents  of  the  cyst,  it  may  be  pos- 
sible to  dispose  of  the  tumor  in  this  way,  even  when  it  seems  to  be 
firmly  wedged  down  in  front  of  the  presenting  part,  and  to  be  hope- 
lessly fixed  in  its  unfavorable  position. 

Failing  either  of  these  resources,  it  may  be  necessary  to  resort  to 
craniotomy,  provided  the  size  of  the  tumor  precludes  the  possibility 
of  delivery  by  forceps. 

The  question  of  the  effect  on  labor  of  ovarian  tumor  which  does 
not  obstruct  the  pelvic  canal  is  one  of  some  interest,  but  there  are 
not  a  sufficient  number  of  cases  recorded  to  throw  much  light  on  it. 
I  am  disposed  to  think  that  labor  generally  goes  on  favorabl3\ 
What  delay  there  is  depends  on  the  inefficient  action  of  the  accessory 
muscles  engaged  in  parturition,  on  account  of  the  extreme  distension 
of  the  abdomen. 

Polypus. — [Polypoid  tumors  sometimes  act  as  serious  obstacles  to 
delivery.  If  long-pedicled  they  may  pass  out  of  the  vagina  in  ad- 
vance of  the  foetus.  If  more  firmly  attached,  they  may  be  pushed 
up  and  secured  by  bringing  down  the  child.  They  are  sometimes 
detached  and  expelled  during  the  labor,  by  the  pressure  of  the  head  ; 
or  are  removed  by  an  ecraseur  if  recognized  early.  One  of  my 
patients  discharged  during  the  birth  of  her  second  child,  the  body  of 
a  very  large  polypus,  which  offered  no  further  obstacle  to  delivery  ; 
after  which  I  returned  it  and  she  carried  it  two  years  more,  before 
she  would  consent  to  have  it  removed. — Ed.] 

There  are  a  few  other  conditions,  connected  with  the  maternal 
structures,  which  may  impede  delivery,  but  which  are  of  compara- 
tively rare  occurrence. 

Vaginal  Cyslocele.— -Amongst  them  is  vaginal  cystocele,  consisting 
of  a  prolapse  of  the  distended  bladder  in  front  of  the  presentation, 
where  it  forms  a  tense  fluctuating  pouch,  which  has  been  mistaken 
for  an  hydrocephalic  head,  or  for  the  bag  of  membranes.  This  com- 
plication is  only  likely  to  arise  when  the  bladder  has  been  allowed  to 
become  unduly  distended  from  want  of  attention  to  the  voiding  of 
urine  during  labor.  The  diagnosis  should  not  offer  any  difficulty, 
for  the  finger  will  be  able  to  pass  behind,  but  not  in  front  of,  the 
swelling,  and  reach  the  presenting  part ;  while  the  pain  and  tenesmus 
will  further  put  the  practitioner  on  his  guard.  The  treatment  con- 
sists in  emptying  the  bladder;  but  there  may  be  some  difficulty  in 
passing  the  catheter  in  consequence  of  the  urethra  being  dragged 
out  of  its  natural  direction.  A  long  elastic  male  catheter  will 
almost  always  pass,  if  used  with  care  and  gentleness.     Should  it  be 


356  LABOR. 

found  impossible  to  draw  off  the  water,  and  this  is  said  to  have  some- 
times happened,  the  tense  pouch  might  be  punctured  without  danger 
by  the  tine  needle  of  an  aspirator  trocar,  and  its  contents  withdrawn. 
When  once  the  viscus  is  emptied,  it  can  easily  be  pushed  above  the 
presenting  part  in  the  intervals  between  the  pains. 

Vesical  Calculus. — In  some  few  cases  difficulties  have  arisen  from 
the  existence  of  a  vesical  calculus.  Should  this  be  pushed  down  in 
front  of  the  head,  it  can  readily  be  understood  that  the  maternal 
structures  would  run  the  risk  of  being  seriously  bruised  and  injured. 
Should  we  make  out  the  existence  of  a  calculus — and,  if  the  presence 
of  one  be  suspected,  the  diagnosis  could  easily  be  made  by  means  of 
a  sound — an  endeavor  should  be  made  to  push  it  above  the  brim  of 
the  pelvis.  If  that  be  found  to  be  impossible,  no  resource  is  left  but 
its  removal,  either  by  crushing,  or  by  rapid  dilatation  of  the  urethra, 
followed  by  extraction.  Should  we  be  aware  of  the  existence  of  a 
calculus  during  pregnancy,  its  removal  should  certainly  be  under- 
taken before  labor  sets  in. 

Hernial  protrusion  in  Douglas's  space  may  sometimes  give  rise  to 
anxiety  from  the  pressure  and  contusion  to  which  it  is  necessarily 
subjected.  An  endeavor  must  be  made  to  replace  it,  and  to  moderate 
the  straining  efforts  of  the  patient ;  and  it  may  be  even  advisable  to 
apply  the  forceps  so  as  to  relieve  the  mass  from  pressure  as  soon  as 
possible.  It  is,  however,  of  great  rarity.  Fordyce  Barker,  in  an 
interesting  paper  on  the  subject,^  records  several  examples,  and  states 
that  he  has  met  with  no  instance  in  which  it  has  led  to  a  fatal  result 
either  to  mother  or  child,  although  it  cannot  but  be  considered  a 
serious  complication. 

Scybalous  masses  tn  the  intestines  may  be  so  hard  and  impacted  as 
to  form  an  obstruction.  The  necessity  of  attending  to  the  state  of 
the  rectum  has  already  been  pointed  out.  Should  it  be  found  im- 
possible to  empty  the  bowel  by  large  enemata,  the  mass  must  be 
mechanically  broken  down  and  removed  by  the  scoop. 

(Edema  of  the  Vulva. — Excessive  oederaatous  infiltration  of  the 
vulva  may  sometimes  cause  obstruction,  and  require  diminution  in 
size,  which  can  be  easily  effected  by  numerous  small  punctures. 

Hsematic  effusions  into  the  cellular  tissue  of  the  vulva  or  vagina 
form  a  grave  complication  of  labor.  Such  blood  swellings  are  most 
usually  met  with  in  one  or  both  labia,  or  under  the  vaginal  wall ;  in 
the  gravest  forms,  the  blood  may  extend  into  the  tissues  for  a  con- 
siderable distance,  as  in  the  case  recorded  by  Cazeaux,  where  it 
reached  upwards  as  far  as  the  umbilicus  in  front,  and  as  far  as  the 
attachment  of  the  diaphragm  behind. 

Conditions  favoring  the  Accident. — The  conditions  associated  with 
pregnancy,  the  distension  and  engorgement  to  which  the  vessels  are 
subjected,  the  interference  with  the  return  of  the  blood  by  the  pres- 
sure of  the  head  during  labor,  and  the  violent  efforts  of  the  patient, 
afforded  a  ready  explanation  of  the  reason  why  a  vessel  may  be 
predisposed  to  rupture  and  admit  of  the  extravasation  of  blood. 

The  accident  is  fortunately  far  from  a  common  one,  although  a 

'  Amer.  Journ.  of  Obstetrics,  vol.  is. 


OBSTRUCTION    FROM    CONDITION    OF    SOFT    PARTS.  357 

sufficient  number  of  cases  are  recorded  to  make  us  familiar  with  its 
Rymptoms  and  risks.  The  dangers  attending  such  effusions  Avould 
seem  to  be  great,  if  the  statistics  given  by  those  who  have  written 
on  the  subject  are  to  be  trusted.  Thus,  out  of  124  cases  collected 
by  various  French  authors,  44  proved  fiatal.  Fordyce  Barker  points 
out  that,  since  the  nature  and  appropriate  treatment  of  the  accident 
have  been  more  thoroughly  understood,  the  mortality  has  been  much 
lessened ;  for  out  of  15  cases  reported  by  Scauzoni  only  1  died,  and 
out  of  22  cases  he  had  himself  seen  2  died,  and  all  these  three  deaths 
were  from  puerperal  fever,  and  not  the  direct  result  of  the  accident.^ 

Situation  of  the  Blood  Effusion. — The  blood  may  be  effused  into 
any  part  of  the  pelvic  cellular  tissue,  or  into  the  labia.  The  accident 
most  often  happens  during  labor  when  the  head  is  low  down  in  the 
pelvis,  not  un frequently  just  as  it  is  about  to  escape  from  the  vulva. 
Hence  the  extravasation  is  more  often  met  with  low  down  in  the 
vagina,  and  more  frequently  in  one  of  the  labia  than  in  any  other 
situation.  I  have  met  with  a  case  in  which  I  had  every  reason  to 
believe  that  an  extravasation  of  blood  had  occurred  within  the 
tissues  immediately  surrounding  the  cervix.  It  is  natural  to  suppose 
that  a  varicose  condition  of  the  veins  about  the  vulva  would  pre- 
dispose to  the  accident,  but  in  most  of  the  recorded  examples  this 
is  not  stated  to  have  been  the  case.  Still,  if  varicose  veins  exist  to 
any  marked  ciegree,  some  anxiety  on  this  point  cannot  but  be  felt. 

l\'me  of  Occurrence. — The  thrombus  occasionally,  though  rarely, 
forms  before  delivery.  Most  commonly  it  first  forms  towards  the  end 
of  labor,  or  after  the  birth  of  the  child.  In  the  latter  case,  it  is  prob- 
able that  the  laceration  in  the  vessels  occurred  before  the  birth  of 
the  child,  and  that  the  pressure  of  the  presenting  |;)art  prevented  the 
escape  of  any  quantity  of  blood  at  the  time  of  laceration. 

Symptoms. — The  symptoms  are  not  by  any  means  characteristic. 
Pain  of  a  tearing  character,  occasionally  very  intense,  and  extending 
to  the  back  and  down  the  thighs,  is  very  generally  associated  with  the 
formation  of  the  throtjibus.  If  a  careful  physical  examination  be 
made,  the  nature  of  the  case  can  readily  be  detected.  When  the  blood 
escapes  into  the  labium,  a  firm,  hard  swelling  is  felt,  which  has  even 
been  mistaken  for  tlie  fcetal  head.  If  the  effusion  implicate  the  in- 
ternal parts  only,  the  diagnosis  may  not  at  first  be  so  evident.  But 
even  then  a  little  care  should  prevent  any  mistake,  for  the  swelling  may 
be  felt  in  the  vagina,  and  may  even  form  an  obstacle  to  the  passage 
of  the  child.  Cazeaux  mentions  cases  in  which  it  was  so  extensive 
as  to  compress  the  rectum  and  urethra,  and  even  to  prevent  the  exit 
of  the  lochia.  In  some  cases  the  distension  of  the  tissues  is  so  great 
that  they  lacerate,  and  then  hemorrhage,  sometimes  so  profuse  as 
directly  to  imperil  the  life  of  the  patient,  may  occur.  The  bursting 
of  the  skin  may  take  plac®  some  time  subsequent  to  the  formation  of 
the  thrombus.  Constitutional  symptoms  will  be  in  proportion  to  the 
amount  of  blood  lost,  either  by  extravasation,  or  externally,  after 
the  rupture  of  the  superficial  tissues.  Occasionally  they  are  con- 
siderable, and  are  the  same  as  those  of  hemorrhage  from  any  cause. 

'  The  Puerperal  Diseases,  p.  60. 


358  LABOR. 

Termination. — The  terminations  of  thrombus  are  either  spontane- 
ous absorption  which  may  occur  if  the  amount  of  blood  extrava- 
sated  be  small ;  or  the  tumor  may  burst,  and  then  there  is  external 
hemorrhage  ;  or  it  may  suppurate,  the  contained  coagula  being  dis- 
charged from  the  cavity  of  the  cyst ;  or  finally  sloughing  of  the 
superficial  tissues  has  occurred. 

Treatment. — The  treatment  must  naturally  vary  with  the  size  of  the 
thrombus,  and  the  time  at  which  it  forms.  If  it  be  met  with  during 
labor,  unless  it  be  extremely  small,  it  will  be  very  apt  to  form  an  ob- 
struction to  the  passage  of  the  child.  Under  such  circumstances  it  is 
clearly  advisable  to  terminate  the  labor  as  soon  as  possible,  so  as  to 
remove  the  obstacle  to  the  circulation  in  the  vessels.  For  this  purpose 
the  forceps  should  be  applied  as  soon  as  the  head  can  be  easily  reached. 
If  the  tumor  itself  obstruct  the  passage  of  the  head,  or  if  it  be  of 
any  considerable  size,  it  will  be  necessary  to  incise  it  freely  at  its 
most  prominent  point  and  turn  out  the  coagula,  controlling  the 
hemorrhage  at  once  by  filling  the  cavity  with  cotton  wadding  satu- 
rated in  a  solution  of  perchloride  of  iron,  while  at  the  same  time, 
digital  compresssion  with  the  tips  of  the  fingers  is  kept  up.  By  this 
means  pressure  is  applied  directly  to  the  bleeding  point,  and  the 
hemorrhage  can  be  controlled  without  difficulty.  This  is  all  the 
more  necessary  if  spontaneous  rupture  have  taken  place,  for  then  the 
loss  of  Ijlood  is  often  profuse,  and  it  is  of  the  utmost  importance  to 
reach  the  site  of  the  hemorrhage  as  nearly  as  possible. 

If  the  thrombus  be  not  so  large  as  to  obstruct  delivery,  or  if  it  be 
not  detected  until  after  the  birth  of  the  child,  the  question  arises 
whether  the  case  should  not  be  left  alone,  in  the  hope  that  absorption 
may  occur,  as  in  most  cases  of  pelvic  hsBmatocele.  This  expectant 
treatment  is  advised  by  Cazeaux,  and  it  seems  to  be  the  most  ra- 
tional plan  we  can  adopt.  True  it  may  take  a  longer  time  for  the 
patient  to  convalesce  completely  than  if  the  coagula  were  removed 
at  once,  and  the  hemorrhage  restrained  by  pressure  on  the  bleeding 
point ;  but  this  disadvantage  is  more  than  counterbalanced  by  the 
absence  of  risk  from  hemorrhage,  and  of  septic<»mia  from  the  sup- 
puration that  must  necessarily  follow.  Softening  and  suppuration 
may  in  many  cases,  occur  in  a  few  days,  necessitating  operation,  but 
the  vessels  will  then  be  probably  occluded,  and  the  risk  of  hemor- 
rhage much  lessened.  Dr.  Fordyce  Barker,  however,  holds  the 
opposite  opinion  and  thinks  that  the  proper  plan  is  to  open  the 
thrombus  early,  controlling  the  hemorrhage  in  the  manner  already 
indicated,  unless  the  thrombus  is  situated  high  in  the  vaginal  canal. 

Risk  of  Subsequent  Septicsemia. — Whenever  the  cavity  of  a  throm- 
bus has  been  opened,  either  by  incision,  or  by  spontaneous  softening 
at  some  time  subsequent  to  its  formation,  it  must  not  be  forgotten 
that  there  is  considerable  "risk  of  septic  absorption.  To  avoid  this, 
care  must  be  taken  to  use  antiseptic  dressings  freely,  such  as  the 
glycerine  of  carbolic  acid  applied  directly  to  the  part,  and  frequent 
vaginal  injections  of  diluted  Condy's  fluid.  Barker  lays  special 
stress  on  the  importance  of  not  removing  prematurely  the  coagula 
formed  by  the  styptic  applications,  for  fear  of  secondary  hemorrhage, 
but  of  allowing  them  to  come  away  spontaneously. 


DYSTOCIA    FROM    FCETUS. 


o.jW 


CHAPTEE  XI. 

DIFFICULT  LABOR   DEPENDING  ON  SOME  UNUSUAL  CONDITION   OF   THE 

FCETUS. 


Fig.  122. 


Plural  Births. — The  subject  of  multiple  pregnancy  in  general 
having  already  been  fully  considered,  we  have  now  only  to  discuss  its 
practical  bearing  as  regards  labor.  Fortunately  the  existence  of 
twins  rarely  gives  rise  to  any  serious  difl&culty.  In  the  large  pro- 
portion of  cases  the  presence  of  a  second  foetus  is  not  suspected  until 
the  birth  of  the  first,  when  the  nature  of  the  case  is  at  once  apparent 
from  the  fact  of  the  uterus  remaining  as  large,  or  nearly  as  large  as 
it  was  before. 

There  may  possibly  be  some  delay  in  the  birth  of  the  first  child, 
inasmuch  as  tlie  extreme  distension  of  the  uterus  may  interfere  with 
its  thoroughly  efficient  action ;  while, 
in  addition,  the  uterine  pressure  is  not 
dh'ectly  conveyed  to  the  ovum  as  in 
single  births,  but  indirectly  through 
the  amniotic  sac  of  the  second  child 
(Fig.  122).  Such  delay  is  especially 
apt  to  arise  when  the  first  child  pre- 
sents by  the  breech,  for,  even  if  the 
body  be  expelled  spontaneously,  diffi- 
culty is  likely  to  occur  with  the  head, 
since  the  uterus  does  not  contract  upon 
it  as  is  ordinarily  the  case.  Hence  the 
intervention  of  the  accoucheur  to  save 
the  life  of  the  child,  by  the  extraction 
of  the  head,  will  be  almost  a  matter  of 
necessity. 

In  the  majority  of  cases,  after  the 
birth  of  the  first  child,  there  is  a  tem- 
porary lull  in  the  pains,  which  soon 
recommence,  generally  in  from  ten  to 
twenty  minutes,  and  the  second  child  is 
rapidly  expelled  ;  for  on  account  of  the 
full  dilatation  of  the  soft  parts,  there  is 
no  obstacle  to  its  delivery.  Sometimes  there  is  a  considerable  inter- 
val before  the  pains  recur,  and  instances  are  recorded  in  which  even 
several  days  have  elapsed  between  the  births  of  the  two  children. 

Treatment. — In  most  cases  the  management  of  twins  does  not  differ 
from  that  of  ordinary  labor.  As  soon  as  we  are  certain  of  the  ex- 
istence of  a  second  foitus,  we  should  inform  the  bystanders,  but  not 


Tvriii  Pregnancy,  Breech  and  Head 
presenting. 


360  LABOR. 

necessarily  tlie  mother,  to  whom  the  news  might  prove  an  unpleasant 
and  even  dangerous  shock.  Then  havmg  taken  care  to  tie  the  cord 
of  the  first  child  for  fear  of  vascular  communication  between  the 
placentae,  our  duty  is  to  wait  for  a  recurrence  of  the  pains.  If  these 
come  on  rapidly,  and  the  presentation  of  the  second  foetus  be  normal, 
its  birth  is  managed  in  the  usual  way. 

Management  when  there  is  Delay  after  the  Birth  of  the  First  Child. — 
If  there  be  any  unusual  delay,  we  have  to  consider  the  proper  course 
to  pursue,  and  on  this  the  opinions  of  authorities  differ  greatly. 
Some  advise  a  delay  of  several  hours,  and  even  more,  if  pains  do  not 
recur  spontaneously  ;  while  others.  Murphy  for  example,  recommend 
that  the  second  child  should  be  delivered  at  once.  Either  extreme 
of  practice  is  probably  wrong,  and  the  safest  and  best  course  is, 
doubtless,  the  medium  one.  The  second  point  to  bear  in  mind  is, 
that,  in  multiple  pregnancy,  on  account  of  the  extreme  distension  of 
the  uterus,  there  is  a  tendency  to  inertia,  and  consequently  to  post- 
partum hemorrhage ;  and  that,  therefore,  it  is  better  that  the  birth 
of  the  second  child  should  be  delayed,  even  for  a  considerable  time, 
rather  than  that  the  patient  should  run  the  risk  attending  an  empty 
and  uncontracted  uterus.  If,  however,  uterine  action  be  present, 
there  is  an  obvious  advantage  in  the  delivery  of  the  second  child 
before  the  dilatation  of  the  passages  passes  off". 

Endeavors  should  he  made  to  Excite  Uterine  Action.- — ^The  best  plan 
would  seem  to  be,  if,  after  waiting  a  quarter  of  an  hour,  labor  pains 
do  not  occur,  to  try  and  induce  them  by  uterine  friction  and  pressure, 
and  by  the  administration  of  a  dose  of  ergot,  to  which,  as  there  can 
be  no  obstacle  to  the  rapid  birth  of  the  second  child,  there  can  be 
now  no  objection.  The  membranes  of  the  second  child  should  always 
be  ruptured  at  once,  if  easily  within  reach,  as  one  of  the  speediest 
means  of  inducing  contraction.  If  no  progress  be  made,  and  speedy 
delivery  be  indicated — a  necessity  which  may  arise  either  from  the 
exhausted  state  of  the  patient,  the  presence  of  hemorrhage,  extremely 
feeble  pulsations  of  the  foetal  heart  (showing  that  the  life  of  the 
second  child  is  endangered),  or  malpresentations  of  the  second  foetus — 
turning  is  probably  the  readiest  and  safest  expedient.  Under  such 
circumstances  the  operation  is  performed  with  great  ease,  since  the 
passages  are  amply  dilated.  After  bringing  down  the  feet,  the  birth 
of  the  body  should  be  slowly  effected,  with  the  view  of  insuring  as 
complete  subsequent  contraction  as  possible.  If  the  head  has  de- 
scended in  the  pelvis,  of  course  turning  is  impossible,  and  the  for- 
ceps must  be  applied. 

Diff cutties  arising  from  Locked  Tivins. — Occasionally  very  serious 
difficulties  arise  from  parts  of  both  foetuses  presenting  simultane- 
ously, and  either  thus  impeding  the  entrance  of  either  child  into  the 
pelvis,  or  getting  locked  together,  so  as  to  render  delivery  impossible 
without  artificial  aid.  Such  difficulties  are  not  apt  to  arise  in  the 
more  ordinary  cases,  in  which  each  child  has  its  own  bag  of  mem- 
branes, since  then  the  foetuses  are  kept  entirely  separate  ;  but  in  those 
in  which  the  twins  are  contained  in  a  common  amniotic  cavity,  or  in 
which  both  sacs  have  burst  simultaneously.    They  are  very  puzzling 


DYSTOCIA    FROM    FOETUS. 


561 


to  tlic  obstetrician,  and  it  may  be  far  from  easy  to  discover  tlie  cause 
of  tlie  obstruction.  Nor  is  it  possible  to  lay  down  any  positive  rules 
for  their  management,  which  must  be  governed,  to  a  considerable 
extent,  by  the  circumstances  of  each  individual  case. 

Nature  of  these  Cases. — Sometimes  both  heads  present  simultane- 
ously at  the  brim,  and  then  neither  can  enter  unless  they  be  unusu- 
ally small  or  the  pelvis  very  capacious,  when  both  may  descend ; 
or  rather  the  first  head  may  descend  low  into  the  pelvic  cavity,  and 
then  the  second  head  enters  the  brim,  and  gets  jammed  against  the 
thorax  of  the  first  child  (Fig.  123).     Eeimann'  relates  a  curious  ex- 

FiG.  123. 


Shows  Head-locking,  both  Children  presenting  Head  first.     (After  Barnes.) 

ample  of  this,  in  which  he  delivered  the  first  head  with  the  forceps, 
but  found  the  body  would  not  follow,  and,  on  examination,  a  second 
head  was  found  in  the  pelvis.  He  then  applied  the  forceps  to  the 
second  head ;  the  body  of  the  first  child  was  then  born,  and  after- 
wards that  of  the  second.  Such  a  mechanism  must  clearly  have 
been  impossible  unless  the  pelvis  had  been  extremely  large. 

Both  Heads  presenting  Simultaneously.- — -Whenever  both  heads  are 
felt  at  the  brim,  it  will  generally  be  found  possible  to  get  one  out  of 
the  way  by  appropriate  manipulation,  one  hand  being  passed  into 
the  vagina,  the  other  aiding  its  action  from  without.  Then  the  for- 
ceps may  be  applied  to  the  other  head,  so  as  to  engage  it  at  once  in 
the  pelvic  cavity.  If  both  have  actually  passed  into  the  pelvis,  as  in 
the  case  just  alluded  to,  the  difficulty  will  be  much  greater.  It  will 
generally  be  easier  to  push  up  the  second  head,  while  the  lower  is 
drawn  out  by  the  forceps,  than  to  deliver  the  second,  leaving  the 
first  in  situ. 


24 


'  Arch.  f.  Gynak.,  1871. 


362 


LABOR. 


Foot  or  Hand  loith  Head. — In  other  cases  a  foot  or  a  hand  may  de- 
scend along  with  the  head,  and  even  the  four  feet  maj  present 
simultaneously.  The  rule  in  the  former  case,  is  to  push  the  part 
descending  with  the  head  out  of  the  way,  and,  in  the  latter,  to  dis- 
engage one  child  as  soon  as  possible.  Great  care  is  necessary,  or  we 
might  possibly  bring  down  the  limbs  of  separate  children. 

Two  Heads  Interlochinrj . — The  most  common  kind  of  difficulty  is 
when  the  first  child  presents  by  the  breech,  and  is  delivered  as  far  as 
the  head,  ^hich  is  then  found  to  be  locked  with  the  head  of  the 
second  child,  which  has  descended  into  the  pelvic  cavity  (Fig.  124). 


Fig,  124. 


Shows  Head-locking,  first  Child  coming  feet  first ;  Impaction  of  Heads  from  Wedging  in  Brim. 

(After  Barnes.) 

D.  Apex  of  wedge,     e,  c.  Base  of  wedge  which  cannot  enter  hrim.     A,  B.  Line  of  decapitatioa 

to  decompose  wedge,  and  enable  head  of  second  child  to  pass. 

Here  it  is  clear  that  the  obstruction  must  be  very  great,  and,  unless 
the  children  are  extremely  small,  insuperable.  The  first  endeavor 
should  be  to  disentangle  the  heads ;  this  is  sometimes  feasible  if  the 


DYSTOCIA    FROM    FOETUS.  363 

second  be  not  deeply  engaged  in  the  pelvis,  and  the  hand  be  passed 
up  so  as  to  push  it  out  of  the  way.  This  will  but  rarely  succeed; 
then  it  may  be  possible  to  apply  the  forceps  to  the  second  head  and 
drag  it  past  the  body  of  the  first  child,  and  this  is  the  method  rec- 
ommended by  Reimann,  who  has  written  an  excellent  paper  on  tlie 
subject.'  Generally  the  sacrifice  of  one  of  the  children  is  essential, 
and  as  the  body  of  the  first  child  must  have  been  born  for  some  time, 
it  is  probable  that  the  pressure  to  which  it  has  been  subjected  will 
have  already  imperilled,  if  it  have  not  destroyed,  its  life,  and  there- 
fore the  plan  usually  recommended  is  to  decapitate.  This  can  easily 
be  done  with  scissors  or  a  wire  ^craseur,  after  which  the  second  child 
is  expelled  without  difficulty,  leaving  the  head  of  the  first  in  utero  to 
be  subsequently  dealt  with. 

Another  mode  of  managing  these  cases  is,  to  perforate  the  upper 
head  and  draw  it  past  the  lower  with  the  cephalotribe  or  craniotomy 
forceps.  This  plan  has  the  disadvantage  of  probably  sacrificing. both 
children,  since  the  other  child  can  hardly  survive  the  pressure  and 
delay,  whereas  the  former  plan  gives  the  second  child  a  fair  chance 
of  being  born  alive. 

Double  Monsters. — In  connection  with  the  subject  of  twin  labor  we 
may  consider  those  rare  cases  in  which  the  bodies  of  the  foetuses  are 
partially  fused  together.  The  mechanism  and  management  of  de- 
livery in  cases  of  double  monstrosity  have  attracted  comparatively 
little  attention,  no  doubt  because  authors  have  considered  them 
matters  of  curiosity  merely,  rather  than  of  practical  importance. 

The  frequent  occurrence  of  such,  monstrosities  in  our  museums, 
and  the  numerous  cases  scattered  through  our  periodical  literature, 
are  sufficient  to  show  that  they  are  not  so  very  rare  as  we  might  be 
inclined  to  imagine ;  and,  as  they  are  likelj'-  to  give  rise  to  formidable 
difficulties  in  delivery,  it  cannot  be  unimportant  to  have  a  clear  idea 
of  the  usual  course  taken  by  nature  in  effecting  such  births,  with 
a  view  of  enabling  us  to  assist  in  the  most  satisfactory  manner  should 
a  similar  case  come  under  our  observation. 

Unfortunately  the  authors  who  have  placed  on  record  the  birth  of 
double  rnonsters,  have  generally  occupied  themselves  more  with  a 
description  of  the  structural  peculiarities  of  the  foetuses,  than  Avith 
the  mechanism  of  their  delivery ;  so  that,  although  the  cases  to  be 
met  with  in  medical  literature  are  very  numerous,  comparatively  few 
of  them  are  of  real  value  from  an  obstetric  pomt  of  view.  Still,  I 
have  been  able  to  collect  the  details  of  a  considerable  number^  in 
which  the  history  of  the  labor  is  more  or  less  accurately  described  ; 
and  doubtless  a  more  extensive  research  would  increase  the  list. 

For  obstetric  purposes  we  may  confine  our  attention  to  four  princi- 
pal varieties  of  double  monstrosity,  which  are  m.et  with  far  more 
frequently  than  any  others.     These  are  : — • 

A.  Two  nearly  separate  bodies  united  in  front,  to  a  varying  ex- 
tent, by  thorax  or  abdomen, 

'   American  Journal  of  Obstetrics,  January,  1877. 
2  Obstet.  Trans,  vol.  viii. 


364  LABOR. 

B.  Two  nearly  separate  bodies  united  back  to  back  by  tlie  sacrum 
and  lower  part  of  the  spinal  column. 

C.  Dicepbalous  monsters,  tlie  bodies  being  single  below,  but  the 
heads  separate. 

D.  The  bodies  separate  below,  but  the  heads  fixed  are  partially 
united. 

This  classification  bj  no  means  includes  all  the  varieties  of  mon- 
sters that  we  may  meet  with.  It  does,  however  include  all  that  are 
likely  to  give  rise  to  much  difficulty  in  delivery ;  and  all  the  cases  I 
have  collected  may  be  placed  under  one  of  these  divisions. 

The  fi.rst  point  that  strikes  us  in  looking  over  the  history  of  these 
deliveries  is  the  frequency  with  which  they  have  been  terminated 
by  the  natural  powers  alone,  without  any  assistance  on  the  part  of 
the  accoucheur.  Thus,  out  of  the  81  cases  no  less  than  20  were  de- 
livered naturally,  and  apparently  without  much  trouble.  JSTothing 
can  better  show  the  wonderful  resources  of  nature  in  overcoming 
difficulties  of  a  very  formidable  kind. 

It  is  pretty  generally  assumed  by  authors  that  the  children  are 
necessarily  premature,  and,  therefore  of  small  size,  and  that  delivery 
before  the  full  term  is  rather  the  rule  than  the  exception.  Duges 
states  that  the  children  are  often  dead,  and  that  putrefaction  has 
taken  place,  which  facilitates  their  expulsion.  Botli  these  assump- 
tions seem  to  me  to  have  been  made  wathout  sufficient  authority,  and 
not  to  be  borne  out  by  the  recorded  facts.  In  only  1  of  the  31  cases 
is  it  mentioned  that  the  children  were  premature  ;  nor  is  there  any 
sufficient  reason  that  I  can  see  why  labor  should  commence  before 
the  full  term  of  gestation. 

Class  A. — By  far  the  greatest  number  are  included  in  the  first 
class — that  in  which  the  bodies  are  nearly  separate,  but  united  by  some 
part  of  the  thorax  or  abdomen.  This  is  the  division  which  includes 
the  celebrated  Siamese  Twins,  an  account  of  whose  birth,  I  may  ob- 
serve, I  have  not  been  able  to  discover.^  Out  of  the  31  cases,  19 
come  under  this  heading.  The  details  of  the  labor  are  briefly  as 
follows : — 1  died  undelivered ;  8  were  terminated  by  the  natural 
powers,  in  3  of  which  the  feet,  and  in  3  the  head  presented;  in  2 
the  presentation  is  doubtful ;  6  were  delivered  by  turning,  or  by 
traction  on  the  lower  extremities  ;  4  were  delivered  instrumentally. 

Footling  Presentation  is  the  most  Favorable. — The  details  of  the 
cases  in  which  the  feet  presented,  or  in  which  turning  was  performed, 
clearly  show  that  footling  presentation  was  by  far  the  most  favor- 
able, and  it  is  fortunate  the  feet  often  present  naturally.  The  infer- 
ence, of  course,  is,  that  version  should  be  resorted  to  whenever  any 
other  presentation  is  met  with  in  cases  of  double  monstrosity  of  this 

['  The  mother  of  these  twins  was  a  Chinese  half-breed,  short,  and  with  a  broad 
pelvis,  and  had  borne  several  children  previously.  She  stated  on  several  occasions 
in  conversation  with  parties  in  Siam,  that  the  twins  were  born  reversed,  the  feet  of 
one  being  followed  by  the  head  of  the  other,  and  that  they  were  veiy  small  and  feeble 
at  birth  and  for  several  months  afterwards.  The  twins  confirmed  this  statement  by 
affirming  that  they  could  when  little  boys  at  play  on  the  ground,  turn  themselves  end 
for  end  upon  the  ensiform  attachment,  up  to  the  age  of  ten  or  twelve,  the  attachment 
being  then  soft  and  pliable. — Harris's  note  to  2d  Amer.  ed.] 


DYSTOCIA    FROM    F(ETUS.  3Go 

type ;  but,  unfortunately,  this  rule  could  rarely  be  carried  into  exe- 
cution, since  we  possess  no  means  of  diagnosing  the  junction  of  the 
fostuses  at  a  sufficiently  early  stage  of  labor  to  admit  of  turning  being 
performed.  It  is  only  under  exceptionably  favorable  circumstances 
that  this  can  be  done ;  as,  for  example,  in  a  case  recorded  by  Molas,^ 
in  which  both  heads  presented,  but  neither  would  enter  the  brim  of 
the  pelvis. 

The  Chief  Difficulty  is  in  the  Delivery  of  the  Heads. — The  great  diffi- 
culty must  of  course  be  in  the  delivery  of  the  heads;  for  in  all  the 
recorded  cases,  with  one  exception,  the  bodies  have  passed  through 
the  pelvis  parallel  to  each  other  with  comparative  ease  until  the 
necks  have  appeared,  and  then,  as  a  rule,  they  could  be  brought  no 
farther.  It  is  clear  that  the  remainder  of  the  ioetuses  could  no  longer 
pass  simultaneously ;  and,  were  direct  traction  continued,  the  heads 
would  be  inextricably  fixed  above  the  brim.  In  accordance  with 
the  direction  of  the  pelvic  axes  the  posterior  head  must  first  engage 
in  the  inlet;  and  in  order  to  effect  this,  it  will  be  necessary  to  carry 
the  bodies  of  the  children  well  over  the  abdomen  of  the  mother. 
This  seems  to  be  a  point  of  primary  importance.  It  would  also  be 
advisable  to  see  that  the  bodies  are  made  to  pass  through  the  pelvis 
with  their  backs  in  the  oblique  diameter.  By  this  means  more  space 
is  gained  than  if  the  backs  were  placed  antero-posteriorly ;  while,  at 
the  same  time,  there  is  less  chance  of  the  heads  hitching  against  the 
promontory  of  the  sacrum  and  symphysis  pubis,  which  otherwise 
would  be  very  apt  to  occur. 

Mode  of  Delivery  when  the  Head  Presents. — When  the  head  pre- 
sents, anci  the  labor  is  terminated  by  the  natural  powers,  delivery 
seems  to  be  accomplished  in  one  of  two  ways. 

In  the  first  and  more  common,  the  head  and  shoulders  of  one  child 
are  born,  its  breech  and  legs  being  subsequently  pushed  through  the 
pelvis  by  a  process  similar  to  that  of  spontaneous  evolution ;  and, 
afterwards,  the  second  child  probably  passes  footling  without  much, 
difficulty. 

Barkow  relates  a  case  in  which  loth  heads  were  delivered  by  the 
forceps,  the  bodies  subsequently  passing  simultaneously.  Two 
similar  instances  are  recorded  in  the  third  and  sixth  volumes  of  the 
"  Obstetrical  Transactions."  When  delivery  takes  place  in  this 
manner,  the  head  of  the  second  child  must  fit  into  the  cavity  formed 
by  the  neck  of  the  first,  and  the  pelvis  must  necessarily  be  suffi- 
ciently roomy  to  admit  of  the  expulsion  of  the  head  of  the  second 
child,  while  its  cavity  is  diminished  in  size  by  the  presence  of  the 
neck  and  shoulders  of  the  first.  Either  of  these  processes  must  ob- 
viously require  exceptionally  favorable  conditions  as  regards  the  size 
of  the  child  and  the  pelvis  ;  and  the  difficulty  in  the  way  of  delivery 
must  be  much  greater  than  when  the  lower  extremities  present. 
Therefore,  I  think  the  rule  should  be  laid  down  that,  when  the  nature 
of  the  case  is  made  out  (and  for  the  purpose  of  accurate  diagnosis  a 

'  M^m.  de  I'Academie,  vol.  i. 


366  LABOR. 

complete  examination  under  anaesthesia  should  be  practised),  turning 
should  be  performed,  and  the  feet  brought  down. 

Mutilation  of  the  Foetuses. — In  the  event  of  its  being  found  impos- 
sible to  effect  delivery  after  a  considerable  portion  of  the  bodies  is 
born,  no  resource  remains  but  the  mutilation  of  the  body  of  one 
child,  so  as  to  admit  of  the  passage  of  the  other.  This  was  found 
necessary  in  one  case  in  which  the  children  presented  by  the  feet, 
and  were  born  as  far  as  the  thorax,  but  could  get  no  further.  The 
body  of  the  anterior  child  was  removed  by  a  circular  incision  as  far 
as  it  had  been  expelled,  which  allowed  the  remaining  portion,  con- 
sisting of  the  head  and  shoulders,  to  re-enter  the  uterus ;  after  this 
the  posterior  child  was  easily  extracted,  and  the  mutilated  foetus 
followed  without  difficulty. 

Class  B. — In  class  B,  in  which  the  children  are  united  back  to 
back,  3  cases  are  recorded,  all  of  which  were  delivered  by  the  natural 
powers.  One  of  these  is  the  case  of  Judith  and  Hel^ne,  the  celebrated 
Hungarian  twins,  who  lived  to  the  age  of  twenty-one.^  Hel^ne  was 
born  as  far  as  the  umbilicus,  and,  after  the  lapse  of  three  hours,  her 
breech  and  legs  descended.  Judith  was  expelled  immediately  after- 
wards, her  feet  descending  first.^  Exactly  the  same  process  occurred 
in  a  case  described  by  M.  Norman,  the  children  being  also  born  alive, 
and  dying  on  the  ninth  day. 

Labor  is  easier  than  in  Class  A. — It  is  probable  that  labor  is  easier 
in  this,  class  of  double  monsters  than  in  the  former,  because  the 
children  are  so  joined  that  there  is  no  necessity  for  the  bodies  to  be 
parallel  to  each  other  during  birth  when  the  head  presents,  and  after 
the  birth  of  the  head  and  shoulders  of  the  first  child,  its  breech  and 
lower  extremities  are  evidently  pushed  down  and  expelled  by  a 
process  of  spontaneous  evolution.  If  the  feet  originally  presented, 
the  mechanism  of  delivery  and  the  rules  to  be  followed  would  be  the 
same  as  in  class  A ;  but  the  difficulty  would  probably  be  greater, 
since  the  juncture  is  not  so  flexible,  and  a  more  complete  parallelism 
of  the  bodies  would  be  necessary  during  extraction. 

Class  C. — In  class  C,  that  of  the  dicephalous  monster,  I  have  found 
the  description  of  the  birth  of  8  cases,  3  of  which  were  terminated 
by  the  natural  powers.  In  two  of  these,  the  process  of  evolution 
was  the  main  agent  in  delivery  ;  one  head  being  born  and  becoming 
fixed  under  the  arch  of  the  pubis,  the  body  being  subsequently  pushed 
past  it,  and  the  second  head  following  without  difficulty.  This  pro- 
cess failing,  the  proper  course  is  to  decapitate  the  firstborn  head,  and 
then  bring  down  the  feet  of  the  child,  when  delivery  can  be  accom- 
plished with  ease.  This  was  the  course  adopted  in  2  out  of  the  8 
cases ;  and  it  may  be  done  with  the  less  hesitation,  since,  from  their 
structural  peculiarities,  it  is  extremely  improbable  that  monsters  of 

1  Born,  Oct.  26,  1701  ;  died,  Feb.  8,  1723. 

[2  The  celebrated  Carolina  twins  born  July  11,  1851,  and  still  living,  were  brought 
into  the  world  by  the  same  method,  but  the  mother  having  a  large  pelvis,  "had  a 
brief  and  easy"  delivery.  The  larger  of  the  two  girls  also  came  first,  as  in  the  Tzoni 
case  of  1701.  These  twins  are  seven  years  older  than  the  Hungarian  sisters  were  at 
death. — Ed.] 


DYSTOCIA    FROxM    FCETUS, 


367 


this  kind  should  survive.  In  the  third  case,  terminated  naturally, 
the  heads  were  said  to  have  been  born  simultaneously,  but  it  seems 
probable  that  the  one  head  lay  in  the  hollow  formed  by  the  neck  of 
the  other,  and  so  rapidly  followed  it.  If  the  feet  presented,  the  case 
may  be  managed  in  the  same  manuer  as  in  class  A. 

Glass  D. — Monstrosities  of  class  D,  in  which  the  heads  are  united, 
the  bodies  being  distinct,  appear  to  be  tlie  most  uncommon  of  all ; 
and  I  can  find  the  description  of  delivery  in  only  2  cases.  One  of 
these  gave  rise  to  great  difficulty ;  the  labor  in  the  other  was  easy. 
We  should  scarcely  anticipate  much  difficulty  in  the  birth  of  monsters 
of  this  type  ;  for,  if  the  head  presented  and  would  not  pass,  we  should 
naturally  perform  craniotomy ;  and  if  the  bodies  came  first,  the 
delivery  of  the  monstrous  head  could  readily  be  accomplished  by 
perforation. 

Result  to  the  Mothers. — The  result  to  the  mothers  in  all  these  cases 
seems  to  have  been  very  favorable.  There  is  only  one  in  which  the 
death  of  the  mother  is  recorded  ;  and  although  in  many  the  result  is 
not  mentioned,  we  may  fairly  assume  that  recovery  took  place. 

Among  difficulties  in  labor,  some  of  the  most  important  are  due  to 
morbid  conditions  of  the  foetus  itself. 

Intra-uterine  Hydrocephalus. — Of  these  the  most  common  as  well 
as  the  most  serious,  is  caused  by  intra-uterine  hydrocephalus  (o-ivino- 
rise  to  a  collection  of  watery  fluid  within  the  cranium),  by  which  the 

Fig.  125. 


Lnbor  Impeded  by  Hydroceplialus. 


dimensions  of  the  child's  head  are  enormously  increased,  and  the 
due  relations  between  it  and  the  pelvic  cavitv  entirelv  destroved 
(Fig.  125).  "  -^  ^ 

_  Its  Danger  both  as  regards  the  Mother  and  Child. — Fortunately,  this 
disease  is  of  comparatively  rare  occurrence,  for  it  is  one  of  great 


368  LABOR. 

gravity  both  as  regards  the  mother  and  child.  As  regards  the 
mother,  the  serious  character  of  the  complication  is  proved  by  the 
statistics  of  Dr.  Keiller,  of  Edinburgh,  who  found  that,  out  of  74 
cases,  no  less  than  16  were  accompanied  by  rupture  of  the  uterus. 
The  reason  of  the  danger  to  which  the  mother  is  subjected  is  obvious. 
In  some  few  cases,  indeed,  the  head  is  so  compressible  that,  provided 
the  amount  of  contained  fluid  be  small,  it  may  be  sufficiently  dimin- 
ished in  size,  by  the  moulding  to  which  it  is  subjected,  to  admit  of 
its  being  squeezed  through  the  pelvis.  In  the  majority  of  cases, 
however,  the  size  of  the  head  is  too  great  for  this  to  occur.  The 
uterus  therefore  exhausts  itself,  and  may  even  rupture,  in  the  vain 
endeavor  to  overcome  the  obstacle  ;  while  the  large  and  distended 
head  presses  firmly  on  the  cervix,  or  on  the  pelvic  tissues,  if  the  os 
be  dilated,  and  all  the  evil  effects  of  prolonged  compression  are  apt 
to  follow. 

Its  Diagnosis  is  not  alicays  easy. — The  diagnosis  of  intra-uterine 
hydrocephalus  is  by  no  means  so  easy  as  the  description  in  obstetric 
works  would  lead  us  to  believe.  It  is  true  that  the  head  is  much 
larger  and  more  rounded  in  its  contour  than  the  healthy  foetal 
cranium,  and  also  that  the  sutures  and  fontanelles  are  more  wide, 
and  admit  occasionally  of  fluctuation  being  perceived  through  them. 
Still  it  is  to  be  remembered  that  the  head  is  always  arrested  above 
the  brim,  where  it  is  consequently  high  up  and  difficult  to  reach,  and 
where  these  peculiarities  are  made  out  with  much  difficulty.  As  a 
matter  of  fact,  the  true  nature  of  the  case  is  comparatively  rarely 
discovered  before  delivery  ;  thus  Chaussier^  found  that  in  more  than 
one-half  of  the  cases  he  collected  an  erroneous  diagnosis  had  been 
made. 

Method  of  Diagnosis. — Whenever  we  meet  with  a  case  in  which 
either  the  history  of  previous  labor,  or  a  careful  examination,  con- 
vinces us  that  there  is  no  obstacle  due  to  pelvic  deformity,  in  which 
the  pains  are  strong  and  forcing,  but  in  which  the  head  persistently 
refuses  to  engage  in  the  brim,  we  may  fairly  surmise  the  existence 
of  hydrocephalus.  Nothing,  however,  short  of  a  careful  examination 
under  aneesthesia,  the  whole  hand  being  passed  into  the  vagina  so  as 
to  explore  the  presenting  part  thoroughly,  will  enable  us  to  be  quite 
sure  of  the  existence  of  this  complication.  Under  these  circum- 
stances such  a  complete  examination  is  not  only  justified  but  impera- 
tive; and,  when  it  has  been  made,  the  difficulties  of  diagnosis  are 
lessened,  for  then  we  may  readily  make  out  the  large  round  mass 
softer  and  more  compressible  than  the  healthy  head,  the  widely  sepa- 
rated sutures,  and  the  fluctuating  fontanelles. 

Pelvic  Presentations  are  frequently  met  ivitJi. — In  a  considerable 
proportion  of  cases — as  many,  it  is  said,  as  1  out  of  6 — the  foetus 
presents  by  the  breech.  The  diagnosis  is  then  still  more  difficult; 
for  the  labor  progresses  easily  until  the  shoulders  are  born,  when  the 
head  is  completely  arrested,  and  refuses  to  pass  with  any  amount  of 
traction  that  is  brought  to  bear  on  it.    Even  the  most  careful  exami- 

•  Gazette  Medicalc,  1864. 


DYSTOCIA    FROM    FCETUS.  3G9 

nation  may  not  now  enable  ns  to  make  out  the  cause  of  the  delay, 
for  the  finger  will  impinge  on  the  comparatively  firm  base  of  the 
skull,  and  may  be  unable  to  reach  the  distended  portion  of  the 
cranium.  At  this  time  abdominal  palpation  might  tlirow  some  lia:ht 
on  the  case,  for  the  uterus  being  tightly  contracted  round  the  head, 
we  might  be  able  to  make  out  its  unusual  dimensions.  The  wasted 
and  shrivelled  appearance  of  the  child's  body,  which  so  often  accom- 
panies hydrocephalus,  would  also  arouse  suspicion  as  to  the  cause  of 
delay.  Od  the  whole  such  cases  may  be  fairly  assumed  to  be  less 
dangerous  to  the  mother  than  when  the  head  presents;  for,  in  the 
latter,  the  soft  parts  are  apt  to  be  subjected  to  prolonged  pressure 
and  contusion  ;  while  in  the  former,  delay  does  not  commence  till 
after  the  shoulders  are  born,  and  then  the  character  of  the  obstacle 
would  be  sooner  discovered,  and  appropriate  means  earlier  taken  to 
overcome  it. 

Treatment.- — -The  treatment  is  simple,  and  consists  in  tapping  the 
head,  so  as  to  allow  the  cranial  bones  to  collapse.  There  is  the  less 
objection  to  this  course,  since  the  disease  almost  necessarily  precludes 
the  hope  of  the  child's  surviving.  The  aspirator  would  draw  off  the 
fluid  effectually,  and  would  at  least  give  the  child  a  chance  of  life  ; 
and,  under  certain  circumstances,  the  birth  of  a  child,  who  lives  for 
a  short  time  only,  may  be  of  extreme  legal  importance.  More  gene- 
rally the  perforator  will  be  used,  and  as  soon  as  it  has  penetrated,  a 
gush  of  fluid  will  at  once  verify  the  diagnosis.  Schroeder  recom- 
mends that,  after  perforation,  turning  should  be  performed,  on  account 
of  the  difiiculty  with  which  the  flaccid  head  is  propelled  through  the 
pelvis.  This  seems  a  very  unnecessary  complication  of  an  already 
sufficiently  troublesome  case.  As  a  rule,  when  once  the  fluid  has 
been  evacuated,  the  pains  being  strong,  as  they  generally  are,  no 
delay  need  be  apprehended.  Should  the  head  not  come  down,  the 
cephalotribe  may  be  applied,  which  takes  a  firmer  grasp  than  the 
forceps,  and  enables  the  head  to  be  crushed  to  a  very  small  size  and 
readily  extracted. 

Treatment  ivlien  the  Breech  Presents. — When  the  breech  presents, 
the  head  must  be  perforated  through  the  occipital  bone,  and  gene- 
rally this  may  be  accomplished  behind  the  ear  without  much  diffi- 
culty. In  a  case  of  Tarnier's^  the  vertebral  column  was  divided  by 
a  bistoury  and  an  elastic  male  catheter  introduced  into  the  vertebral 
canal,  through  which  the  intra-cranial  fluid  escaped,  the  labor  being 
terminated  spontaneously.  In  any  case  in  which  it  is  found  difficult, 
to  reach  the  skull  with  the  perforator  this  procedure  should  certainly 
be  tried. 

Other  forms  of  dropsical  effusion  may  give  rise  to  some  difficulty, 
but  by  no  means  so  serious.  In  a  few  rai'c  cases  the  thorax  has 
been  so  distended  with  fluid  as  to  obstruct  the  passage  of  the  child. 
Ascites  is  somewhat  more  common  ;  and,  occasionally,  the  child's 
bladder  is  so  distended  with  urine  as  to  prevent  the"^  birth  of  the 

'  Hergott,  Maladies  Foetales  qui  pendent  faire  obstacle  k  I'accouchement.     Paris, 

1878. 


370  LABOR. 

bodj.  The  existence  of  any  of  these  conditions  is  easily  ascertained  ; 
for  the  head  or  breech,  whichever  happens  to  present,  is  delivered 
without  difficulty,  and  then  the  rest  of  the  body  is  arrested.  This 
will  naturally  cause  the  practitioner  to  make  a  careful  exploration 
when  the  cause  of  the  delay  will  be  detected. 

The  treatment  consists  in  the  evacuation  of  the  fluid  by  puncture. 
In  the  case  of  ascites,  this  should  always  be  done,  if  possible,  by  a 
fine  trocar  or  aspirator,  so  as  not  to  injure  the  child.  This  is  all  the 
more  important  since  it  is  impossible  to  distinguish  a  distended 
bladder  from  ascites,  and  an  opening  of  any  size  into  that  viscus 
might  prove  fatal,  whereas  aspiration  would  do  little  or  no  harm, 
and  would  prove  quite  as  efficacious. 

Foetal  Tumors  Obstructing  Delivery. — Certain  foetal  tumors  may 
occasion  dystocia,  such  as  malignant  growths,  or  tumors  of  the 
kidney,  liver,  or  spleen.  Gases  of  this  kind  are  recorded  in  most 
obstetric  works.  Hydro-encephacele,  or  hydro -rachitis,  depending 
on  defective  formation  of  the  cranial  or  spinal  bones,  with  the  for- 
mation of  a  large  protruding  bag  of  fluid,  is  not  very  rare.  The 
diagnosis  of  all  such  cases  is  somewhat  obscure,  nor  is  it  possible  to 
lay  down  any  definite  rules  for  their  management,  which  must  vary 
according  to  the  particular  exigencies.  The  tumors  are  rarely  of 
sufficient  size  to  prove  formidable  obstacles  to  delivery,  and  many  of 
them  are  very  compressible.  This  is  especially  the  case  with  spina 
bifida  and  similar  <;ystic  growths.  Puncture,  and  in  the  more  solid 
growths  of  the  abdomen  or  thorax,  evisceration  may  be  required. 

Other  Gonrjenital  Deformities. — Other  deformities,  such  as  the  anen- 
cephalous  foetus,  or  defective  development  of  the  thorax  or  abdominal 
parietes  with  protrusion  of  the  viscera,  are  not  likely  to  cause  any 
difficulty  ;  but  they  may  much  embarrass  the  diagnosis  by  the  strange 
and  unusual  presentation  that  is  felt.  If,  in  any  case  of  doubt,  a'full 
and  careful  examination  be  undertaken,  introducing  the  whole  hand 
if  necessary,  no  serious  mistake  is  likely  to  be  made. 

Dystocia  frorti  Excessive  Development  of  the  Fcetus. — In  addition  to 
dystocia  from  morbid  conditions  of  the  foetus,  difficulties  may  arise 
from  its  undue  development,  and  especially  from  excessive  size  and 
advanced  ossification  of  the  skull.  This  last  is  especially  likely  to 
cause  delay.  Even  the  slight  difference  in  size  between  the  male 
and  female  head  was  found  by  Simpson  to  have  an  appreciable  effect 
in  increasing  the  difficulty  of  labor,  when  the  statistics  of  a  large 
number  of  cases  were  taken  into  account ;  for  he  proved  beyond 
doubt  that  the  difficulties  and  casualties  of  labor  occurred  in  de- 
cidedly larger  proportion  in  male  than  in  female  births.  Other  cir- 
cumstances, besides  sex,  have  an  important  effect  on  the  size  of  the 
child.  Thus  Duncan  and  Hecker  have  shown  that  it  increases  in 
proportion  to  the  age  of  the  mother  and  the  frequency  of  the  labors, 
while  the  size  of  the  parents  has  no  doubt  also  an  important  bearing 
on  the  subject. 

Although  these  influences  modify  the  results  of  labor  en  masse., 
they  have  little  or  no  practical  bearing  on  any  particular  case,  since 


DEFORMITIES    OF    THE    PELVIS.  871 

it  is  impossible  to  estimate  either  the  size  of  the  head,  or  the  degree 
of  its  ossification,  until  labor  is  advanced. 

Its  Treatment. — When  labor  is  retarded  by  undue  ossification  or 
large  size  of  the  head,  the  case  must  be  treated  on  the  same  general 
principles  which  guide  us  when  the  want  of  proportion  is  caused  by 
pelvic  contraction.  Hence,  if  delay  arise,  Avhich  the  natural  powers 
are  insufficient  to  overcome,  it  will  seldom  happen  that  the  dis[)ro- 
portion  is  too  great  for  the  forceps  to  overcome.  If  we  fail  to  de- 
liver by  it,  no  resource  is  left  but  perforation. 

Large  Size  of  the  Body  rarely  causes  Belay. — Large  size  of  the 
body  of  the  child  is  still  more  rarely  a  cause  of  difficulty,  for,  if  the 
head  be  born,  the  compressible  trunk  will  almost  always  follow. 
Still,  a  few  authentic  cases  are  on  record,  in  which  it  was  found  im- 
possible to  extract  the  foetus  on  account  of  the  unusual  bulk  of  its 
shoulders  and  thorax.  Should  the  body  remain  firmly  impacted 
after  the  birth  of  the  head,  it  is  easy  to  assist  its  delivery  by  traction 
on  the  axillae,  by  gently  aiding  the  rotation  of  the  shoulders  into  the 
antero-posterior  diameter  of  the  pelvic  cavity,  and,  if  necessary,  by 
extracting  the  arms,  so  as  to  lessen  the  bulk  of  the  part  of  the  body 
contained  in  the  pelvis.  Hicks  relates  a  case  in  which  evisceration 
was  required  for  no  other  apparent  reason  than  the  enormous  size  of 
the  body.  The  necessity  for  any  such  extreme  measure  must,  of 
course,  be  of  the  greatest  possible  rarity ;  and  it  is  quite  exceptional 
for  difficulty  from  this  source  to  be  beyond  the  powers  of  nature  to 
overcome. 


CHAPTER    XII. 

DEFORMITIES  OF  THE  PELVIS, 

Deformities  of  the  pelvis  form  one  of  the  most  important  sub- 
jects of  obstetric  study,  for  from  them  arise  some  of  the  gravest 
difficulties  and  dangers  connected  with  parturition.  A  knowledge, 
therefore,  of  their  causes  and  effects,  and  of  the  best  mode  of  de- 
tecting them,  either  during  or  before  labor,  is  of  paramount  necessity ; 
but  the  subject  is  far  from  easy,  and  it  has  been  rendered  more  diffi- 
cult than  it  need  be,  from  over  anxiety  on  the  part  of  obstetricians 
to  force  all  varieties  of  pelvic  deformities  within  the  limits  of  their 
favorite  classification, 

Bifficulties  of  Closfifcation. — Many  attempts  in  this  direction  have 
been  made,  some  of  which  are  based  on  the  causes  on  which  the 
deformities  depend,  others  on  the  particular  kind  of  deformity  pro- 
duced. The  changes  of  form,  however,  are  so  various  and  irregular, 
and  similar,  or  apparently  similar,  causes  so  constantly  produce  dif- 
ferent effects,  that  all  such  endeavors  have  been  more" or  less  unsuc- 


372  LABOR. 

cessful.  For  example,  we  find  that  rickets  (of  all  causes  of  pelvic 
deformity  the  most  important)  generally  produces  a  narrowing  of 
the  conjugate  diameter  of  the  brim ;  while  the  analogous  disease, 
osteo-raalacia,  occurring  in  adult  life,  generally  produces  contraction 
of  the  transverse  diameter,  with  approximation  of  the  pubic  bones, 
and  relative  or  actual  elongation  of  the  conjugate  diameter.  We 
might,  therefore,  be  tempted  to  classify  the  results  of  these  two 
diseases  under  separate  heads,  did  we  not  find  that,  when  rickets 
aftects  children  who  are  running  about,  and  subject  to  mechanical 
influences  similar  to  those  acting  upon  patients  suffering  from  osteo- 
malacia, a  form  of  pelvis  is  produced  hardly  distinguishable  from  that 
met  with  in  the  latter  disease. 

Most  Simple.  Classification. — On  the  whole,  therefore,  the  most 
simple,  as  well  as  the  most  scientific,  classification  is  that  which  takes 
as  its  basis  the  particular  seat  and  nature  of  the  deformity.  Let  us 
first  glance  at  the  most  common  causes. 

Causes  of  Pelvic  Deformity. — The  key  to  the  particular  shape  as- 
sumed by  a  deformed  pelvis  will  be  found  in  a  knowledge  of  the  cir- 
cumstances which  lead  to  its  regular  development  and  normal  shape 
in  a  state  of  health.  The  changes  produced  may,  almost  invariably, 
be  traced  to  the  action  of  the  same  causes  which  produce  a  normal 
pelvis,  but  which,  under  certain  diseased  conditions  of  the  bones  or 
articulations,  induce  a  more  or  less  serious  alteration  in  form.  These 
have  been  already  described  in  discussing  the  normal  anatomy  of  the 
pelvis,  and  it  will  be  remembered  that  they  are  chiefly  the  weight  of 
the  body,  ti'ausmitted  to  the  iliac  bones  through  the  sacro-iliac  joints, 
and  counter-pressure  on  these,  acting  through  the  acetabula.  Some- 
times they  act  in  excess  on  bones  which  are  healthy,  but  possibly 
smaller  than  usual,  and  the  result  may  be  the  formation  of  certain 
abnormalities  in  the  size  of  the  various  pelvic  diameters.  At  other 
times  they  operate  on  bones  which  are  softened  and  altered  in  texture 
bv  disease,  and  which,  therefore,  yield  to  the  pressure  far  more  than 
healthy  bones. 

Tlie  two  diseases  which  chiefly  operate  in  causing  deformity  are 
rickets  and  osteo-malacia.  Into  the  essential  nature  and  symptoma- 
tology of  these  complaints  it  would  be  out  of  place  to  enter  here  ;  it 
may  suffice  to  remind  the  reader  that  they  are  believed  to  be  patho- 
logically similar  diseases,  with  the  important  practical  distinction 
that  the  former  occurs  in  early  life  before  the  bones  are  completely 
ossified,  and  that  the  latter  is  a  disease  of  adults  producing  softening 
in  bones  that  have  been  hardened  and  developed.  This  difference 
affords  a  ready  explanation  of  the  generally  resulting  varieties  of 
pelvic  deformity. 

Effects  of  Bickets. — Kickets  commences  very  early  in  life,  some- 
times, it  is  believed,  even  in  utero.  It  rarely  produces  softening  of 
the  entire  bones,  and  only  in  cases  of  Yerj  great  severity  of  those 
parts  of  the  bones  that  have  been  already  ossified.  The  eft'ects  of  the 
disease  are  principally  apparent  in  the  cartilaginous  portions  of  the 
bones,  in  which  osseous  deposit  has  not  yet  taken  place.  The  bones, 
therefore,  are  not  subject  to  uniform  change,  and  this  fact  has  an 


DEFORMITIES    OF    THE    PELVIS.  373 

important  influence  in  determining  their  shape.  Eickety  chiklren 
also  have  imperfect  musculai'  development;  thej  do  not  run  about 
in  the  same  way  as  other  children,  they  are  often  continuously  in  the 
recumbent  or  sitting  postures,  and  thus  the  weight  of  the  trunk  is 
brought  to  bear,  more  than  in  a  state  of  health,  on  the  softened  bones. 
For  the  same  reason  counter-pressure  through  the  acetabula  is  absent 
or  comparatively  slight.  AYhen,  however,  the  disease  occurs  for  the 
lirst  time  in  children  who  are  able  to  run  about,  the  latter  comes  into 
operation,  and  modifies  the  amount  and  nature  of  the  deformity.  It 
is  to  be  observed  that  in  rickety  children  the  bones  are  not  only 
altered  in  form  from  pressure,  but  are  also  imperfectlv  developed, 
and  this  materially  modifies  the  deformity.  When  ossific  matter  is 
deposited,  the  bones  become  hard  and  cease  to  bend  under  external 
influences,  and  retain  forever  the  altered  shape  they  have  assumed. 

Effects  of  Osteo-malacia. — In  osteo-malacia,  on  the  contrary,  the 
already  hardened  bones  become  softened  uniformly  through  all  their 
textures,  and  thus  the  changes  which  are  impressed  upon  them  are 
much  more  regular,  and  more  easily  predicated.  It  is,  however,  an 
infinitely  less  common  cause  of  pelvic  deformity  than  rickets,  as  is 
evidenced  by  the  fact  that  in  the  Paris  Maternity  in  a  period  of  six- 
teen years,  402  cases  of  deformity  due  to  rickets  occurred  to  1  due 
to  osteo-malacia.^ 

[Osteo-malacia  not  an  American  Disease. — Out  of  112  CiBsarean 
operations  in  the  United  States,  not  one  was  performed  for  osteo- 
malacia. Many  of  our  chief  obstetricians  have  never  seen  a  case. 
In  a  few  instances  foreigners  have  come  here  with  the  disease  and 
been  delivered  by  the  forceps  or  craniotomy,  but  I  have  yet  to  hear 
of  an  extreme  rostrate  pelvis  being  discovered  in  our  country. — Ed] 

Their  varying  Frequency. — The  frequency  of  both  diseases  varies 
greatly  in  different  countries,  and  under  different  circumstances. 
Eickets  is  much  more  common  amongst  the  poor  of  large  cities, 
whose  children  are  ill-fed,  badly  clothed,  kept  in  a  vitiated  atmo- 
sphere, and  subjected  to  unfavorable  hygienic  conditions.  Deformi- 
ties are,  therefore  more  common  in  them  than  in  the  more  healthy 
children  of  the  upper  classes,  or  of  the  rural  population.^  The  higher 
degrees  of  deformity,  necessitating  the  Ctesarean  section,  or  crani- 
otomy, are  in  this  country  of  extreme  rarity  ;  while,  in  certain  districts 
on  the  Continent,  they  seem  to  be  so  frequent  that  these  ultimate 
resources  of  the  obstetric  art  have  to  be  constantly  employed. 

Effects  of  Ossification  of  Pelvic  Articulations. — In  another  class  of 
cases  the  ordinary  shape  is  modified  by  weight  and  counter-pressure 
operating  on  a  pelvis  in  which  one  or  more  of  the  articulations  is 
ossified.  In  this  way  we  have  produced  the  oUiquely  ovate  pelvis  of 
Naegele,  or  the  still  more  uncommon  transversely  contracted  pelvis  of 
Eobert. 

1  Staneseo,  Recherches  Cliniqnes  sur  leis  Eetrt'cissetnents  dii  Bassin. 

2  [These  appear  to  be  more  common  among  the  blacks  of  Alabama  and  Louisiana, 
than  any  other  part  of  our  population  ;  and  in  these  States  the  Cesarean  operation 
has  been  the  most  frequently  performed  of  any  in  the  Union. — Ed.] 


874  LABOR. 

Other  Causes  of  Pelvic  Deformity. — A  certain  number  of  deformed 
pelves  cannot  be  referred  to  a  modification  of  the  ordinary  develop- 
mental changes  of  the  bones.  Amongst  these  are  the  deformities 
resulting  from  spondylolithesis,  or  downward  dislocation  of  the  lower 
lumbar  vertebras ;  from  displacements  of  the  sacrum,  produced  by 
curvatures  of  the  spinal  column  ;  or  from  diseases  of  the  pelvic  bones 
themselves,  such  as  tumors,  malignant  growths,  and  the  like. 

Equally  Enlarged  Pelvis. — The  first  class  of  deformed  pelves  to  be 
considered  is  that  in  which  the  diameters  are  altered  from  the  usual 
standard,  without  any  definite  distortion  of  the  bones ;  and  such  are 
often  mere  congenital  variations  in  size,  for  which  no  definite  expla- 
nation can  be  given.  Of  this  class  is  the  pelvis  which  is  equally 
enlarged  in  all  its  diameters  {pelvis  sequahiliter  justo  major)^  which  is 
of  no  obstetric  consequence,  except  inasmuch  as  it  may  lead  to  pre- 
cipitate labor,  and  is  not  likely  to  be  diagnosed  during  life. 

Equally  Contracted  Pelvis. — The  corresponding  diminution  of  all 
the  pelvic  diameters  {j)elvis  eequahiliter  jiisto  inirior)  may  be  met  with 
in  women  who  are  apparently  well  formed  in  every  respect,  and 
whose  external  conformation  and  previous  history  give  no  indica- 
tion of  the  abnormality.  Sometimes  the  diminution  amounts  to 
half  an  inch  or  more,  and  it  can  readily  be  understood  that  such  a 
lessening  in  the  capacity  of  the  pelvis  would  give  rise  to  serious 
difficulty  in  labor.  Thus,  in  3  cases  recorded  by  Naegele  a  fatal  re- 
sult followed ;  in  2  after  difficult  instrumental  delivery,  and  in  the 
third  after  rupture  of  the  uterus.  The  equally  lessened  pelvis,  how- 
ever, is  of  great  rarity.  An  unusually  small  pelvis  may  be  met  with 
in  connection  with  general  small  size,  as  in  dwarfs.  It  does  not 
necessarily  follow,  because  a  woman  is  a  dwarf,  that  the  pelvis  is  too 
small  for  parturition.  On  the  contrary,  many  such  women  have 
borne  children  without  difficulty. 

The  Undeveloped  Pelvis. — In  some  cases  a  pelvis  retains  its  in- 
fantile characteristics  after  puberty  (Fig.  126).  The  normal  develop- 
ment of  the  pelvis  has  been  interfered  with  possibly  from  premature 
ossification  of  the  different  portions  of  the  innominate  bones,  or  from 
arrest  of  their  growth  from  a  weakly  or  rachitic  constitution.  The 
measurements  of  these  pelves  are  not  alwaj's  below  the  normal 
standard,  they  may  continue  to  grow,  although  they  have  not  de- 
veloped. The  proportionate  measurements  of  the  various  diameters 
will  then  be  as  in  the  infant ;  and  the  antero-posterior  diameter  may 
be  longer,  or  as  long,  as  the  transverse,  the  ischia  comparatively 
near  each  other,  and  the  pubic  arch 'narrow.  Such  a  form  of  pelvis 
will  interfere  with  the  mechanism  of  delivery,  and  unusual  difficulty 
in  labor  will  be  experienced.  Difficulties  from  a  similar  cause  may 
be  expected  in  very  young  girls.  Here,  however,  there  is  reason  to 
hope  that,  as  age  advances,  the  pelvis  will  develop,  and  subsequent 
labors  be  more  easy. 

Afasculine  or  Funnel-shaped  Pelvis. — The  masculine^  or  funnel- 
shaped  pelvis  owes  its  name  to  its  approximation  to  the  type  of  the 
male  pelvis.  The  bones  are  thicker  and  stouter  than  usual,  the  con- 
jugate diameter  of  the  brim  longer,  and  the  whole  cavity  rendered 


DEFORMITIES    OF    THE    PELVIS. 


375 


deeper  and  narrower  at  its  lower  part  by  the  nearness  of  the  ischial 
tuberosities.  It  is  generally  met  with  in  strong  muscular  women 
following  laborious  occupations,  and  Dr.  Barnes,  from  his  experience 
in  the  Royal  Maternity  Charity,  says  that  it  chiefly  occurs  in  weavers 
in  the  neighborhood  of  Bethual  Green,  who  spend  most  of  their 

Fig.  126. 


Adult  Pelvis  Retaining  its  Infantile  Type. 

time  in  the  sitting  posture.  "The  cause  of  this  form  of  pelvis  seems 
to  be  an  advanced  condition  of  ossification  in  a  pelvis  which  would 
otherwise  have  been  infantile^  brought  about  by  the  development 
of  unusual  muscularity,  corresponding  to  the  laborious  employment 
of  the  individual."  The  difficulties  in  labor  will  naturally  be  met 
with  towards  the  outlet,  where  the  funnel  shape  of  the  cavity  is  most 
apparent. 

Contraction  of  Conjugate  Diameter  of  Brim. — Diminution  of  the 
antero- posterior  diameter  is  most  frequently  limited  to  the  brim,  and 
is  by  far  the  most  common  variety  of  pelvic  deformity.  In  its 
slighter  degrees  it  is  not  necessarily  dependent  on  rickets,  although 
when  more  marked  it  almost  invariably  is  so.  When  unconnected 
with  rickets,  it  probably  can  be  traced  to  some  injurious  influence 
before  the  bones  have  ossified,  such  as  increased  pressure  of  the  trunk 
from  carrying  weights  in  early  childhood,  and  the  like.  By  this 
means  the  sacrum  is  unduly  depressed,  and  projects  forwards,  so  as 
to  slightly  narrow  the  conjugate  diameter. 

Mode  of  production  in  Rickets. — When  caused  by  rickets  the  amount 
of  the  contraction  varies  greatly,  sometimes  being  very  slight,  some- 
times sufficient  to  prevent  the  passage  of  the  child  altogether,  and 
necessitate  craniotomy  or  the  Csesarean  section.  The  sacrum,  softened 
by  the  disease,  is  pressed  vertically  downwards  by  the  weight  of  the 
body,  its  descent  being  partially  resisted  by  the  already  ossified  por- 
tions of  the  bone,  so  that  the  result  is  a  downward  and  forward 
movement  of  the  promontory.  The  upper  portion  of  the  sacral  con- 
cavity is  thus  directed  more  backwards;    but,  as  the  apex  of  the 


376  LABOR. 

bone  is  drawn  forwards  by  the  attaclirnent  of  the  perineal  muscles 
to  the  coccyx,  and  by  tlie  sacro-ischiatic  ligaments,  a  sharp  curve  of 
its  lower  part  in  a  forward  direction  is  established.^ 

Occasional  Increase  of  Transverse  Diameter. — The  depression  of  the 
sacral  promontory  would  tend  to  produce  strong  traction,  through 
the  sacro-iliac  ligaments,  on  the  posterior  ends  of  tbe  sacro-cotyloid 
beams,  and  thus  induce  expansion  of  the  iliac  bones,  and  consequent 
increase  of  the  transverse  diameter  of  the  brim.  So  an  unusual 
length  of  the  transverse  diameter  is  very  often  described  as  accom- 
panying this  deformity,  but  probably  it  is  not  so  often  apparent  as 
might  otherwise  be  expected,  on  account  of  the  imperfect  develop- 
ment of  the  bones  generally  accompanying  rickets  ;  and  Barnes^  says 
that  in  the  parts  of  London  where  deformities  are  most  rife,  any 
enlargement  of  the  transverse  diameter  is  exceedingly  rare.  Fre- 
quently the  sacrum  is  not  only  depressed,  but  displaced  more  or  less 
to  one  side,  most  generally  to  the  left,  thus  interfering  with  the  regu- 
lar shape  of  the  deformed  brim.  This  is  often  the  result  of  a  lateral 
flexion  of  the  spinal  column,  depending  on  the  rachitic  diathesis. 

Cavity  of  Pelvis  is  generally  not  Affected. — In  most  cases  of  this 
kind  the  cavity  of  the  pelvis  is  not  diminished  in  size,  and  is  often 
even  more  than  usually  wide.  The  constant  pressure  on  the  ischia, 
which  the  sitting  posture  of  the  child  entails,  tends  to  force  them 
apart,  and  also  to  widen  the  pubic  arch.  Considerable  advantage 
results  from  this  in  cases  in  wliich  we  have  to  perform  obstetric 
operations,  as  it  gives  plenty  of  room  for  manipulation. 

Figure-of-eight  Deformity. — In  a  few  exceptional  cases  the  narrow- 
ing of  the  conjugate  diameter  is  increased  by  a  backward  depression 
of  the  symphysis  pubis,  which  gives  the  pelvic  brim  a  sort  of  figure- 
of-eight  shape  (Fig.  127).     The  most  reasonable  explanation  of  this 

Fig.  127. 


Rickety  Pelvis,  witli  backward  depression  of  the  Symphysis  Pubis. 

peculiarity  seems  to  be,  that  it  is  the  result  of  the  muscular  contrac- 
tion of  the  recti  muscles,  at  their  point  of  attachment,  when  the 

['  In  the  State  of  Louisiana,  where  there  have  heen  nineteen  Cesarean  sections, 
and  where  rickets  among  the  blacks  has  in  certain  localities  heen  very  prevalent,  I 
am  informed  that  renification  of  the  pelvis  is  increased  by  the  habit  of  the  sound 
children  carrying  the  rachitic  ones  pig-a-back. — Ed.] 

2  Lectures  on  Obst.  Operations,  p.  280. 


DEFORMITIES    OF    THE    PELVIS. 


377 


centre  of  gravity  of  the  body  is  thrown  backwards,  on  account  of 
the  projection  of  the  sacral  promontory.  Sometimes  also  the  antero- 
posterior diameter  of  the  cavity  is  unusually  loosened  by  the  disap- 
pearance of  the  vertical  curvature  of  the  sacrum,  which,  instead  of 
forming  a  distinct  cavity,  is  nearly  flat  (Fig.  128). 


Fio.  128. 


Fig.  129. 


Flatness  of  Sacrum  with  Narrowing  of 
Pelvic  Cavity. 


Pelvis  deformed  liy  Spondylolithesis. 
(After  Kilian.) 


Spondylolithesis.— in  a  few  rare  cases,  to  which  attention  was  first 
called  in  1853  by  Kilian  of  Bonn,  a  very  formidable  narrowing  of 
the  conjugate  diameter  of  the  pelvic  brim  is  produced,  by  a  down- 
ward displacement  of  the  fourth  and.  fifth  lumbar  vertebra,  whicli 
become  dislocated  forward,  or  if  not  actually  dislocated,  at  least 
separated  from  their  several  articulations  to  a  sufficient  extent  to 
encroach  very  seriously  on  the  dimensions  of  the  pelvic  inlet.  This 
condition  is  known  as  spondylolithesis.     (Fig.  129.) 

The  effect  of  this  is  sufficiently  obvious,  for  the  projection  of  the 
lumbar  vertebree  prevents  the  passage  of  the  child.  To  such  an  ex- 
tent is  obstruction  thus  produced,  that,  in  the  majority  of  the  recorded, 
cases,  the  Cc"esarean  section  was  necessary.  The  true  conjugate  diam- 
eter, that  between  the  promontory  of  the  sacrum,  and  the  symphysis 
pubis,  is  increased  rather  than  diminished ;  but,  for  all  practical  pur- 
poses, the  condition  is  similar  to  extreme  narrowing  of  the  conju- 
gate from  rickets,  for  the  bodies  of  the  displaced  vertebrae  project 
into  and  obstruct  the  pelvic  brim. 

The  cause  of  this  deformity  seems  to  be  different  in  different  cases. 
In  some  it  seems  to  have  been  congenital,  and  in  others  to  have  de- 
pended on  some  antecedent  disease  of  the  bones,  such  as  tuberculosis 
or  scrofula,  producing  inflammation  and  softening  of  the  connection 
between  the  last  lumbar  vertebra  and  the  sacrum,  thus  permitting 
downward  displacement  of  the  bones.  Lambl  believed  that  it  gene- 
rally followed  spina  bifida,  which  had  become  partially  cured,  but 
which  had  produced  deformity  of  the  vertebrae,  and  favored  their 
25 


378  LABOR. 

dislocation.  Brodliurst/  on  the  other  hand,  thinks  that  it  most  prob- 
ably depends  on  rachitic  inflammation  and  softening  of  the  osseous 
and  ligamentous  structures,  and  that  it  is  not  a  dislocation  in  the 
strict  sense  of  the  word. 

Narrowmrj  of  the  Ohlique  Diameter. — The  most  marked  examples 
of  narrowing  of  both  oblique  diameters  depend  on  osteo-malacia.  In 
this  disease,  as  has  already  been  remarked,  the  bones  are  uniformly 
softened  ;  and  the  alterations  in  form  are  further  influenced  by  the 
fact  that  the  disease  commences  after  union  of  the  separate  portions^ 
of  the  OS  innominatum  has  been  completely  effected.  The  amount  of 
deformity  in  the  worst  cases  is  very  great,  and  frequently  renders 
delivery  impossible  without  the  C^esarean  section.  Sometimes  the 
softening  of  the  bones  proves  of  service  in  delivery,  by  admitting  of 
the  dilatation  of  the  contracted  pelvic  diameter  by  the  pressure  of 
the  presenting  part,  or  even  by  the  hand.  Some  curious  cases  are 
on  record  in  which  the  deformity  was  so  great  as  to  apparently  re- 
quire the  Cajsarean  section  but  in  which  the  softened  bones  eventu- 
ally yielded  sufhciently  to  render  this  unnecessary. 

Mode  of  Production  in  Osteo-malacia.— 'VI^q  weight  of  the  body  de- 
presses the  sacrum  in  a  vertical  direction,  and  at  the  same  time  com- 
presses its  component  parts  together,  so  as  to  approximate  the  base 
and  apex  of  the  bone,  and  narrow  the  conjugate  diameter  of  the  brim. 

Fig.  130. 


Osteo-malacic  Pelvis. 


by  causing  the  promontory  to  encroach  upon  it.  The  most  charac- 
teristic changes  are  produced  by  the  pushing  inwards  of  the  walls  of 
the  pelvis  at  the  cotyloid  cavities,  in  consequence  of  pressure  exerted 
at  these  points  through  the  femurs.  The  effect  of  this  is  to  dimin- 
ish both  oblique  diameters,  giving  the  brim  somewhat  the  shape  of 
a  trefoil,  or  an  ace  of  clubs.  The  sides  of  the  pubis  are  at  the  same 
time  approximated,  and  may  become  almost  parallel,  and  the  true 
conjugate  may  be  even  lengthened  (Fig.  130).     The  tuberosities  of 

1  Obst.  Trans.,  vol.  vi.  p.  97. 


DEFORMITIES    OP    THE    PELVIS, 


379 


the  ischia  arc  also  compressed  together,  with  the  rest  of  the  lateral 
pelvic  wall,  so  that  the  outlet  is  greatly  deformed  as  well  as  the  brim 
(Fig.  181). 


Fig.  131. 


Extreme  Degree  of  Osteo-malacic  Deformity. 

Ohliquely  Contracted  Pelvis. — That  form  of  deformity  in  which  one 
oblique  diameter  only  is  lessened,  has  received  considerable  attention, 
from  having  been  made  the  subject  of  special  study  by  JSTaegele,  and 
is  generally  known  as  the  obliquely  contracted  pelvis  (Fig.  132).  It  is 
a  condition  that  is  very  rarely  met 
with,  although  it  is  interesting  from  Fig.  132. 

an  obstetric  point  of  view,  as  throw- 
ing considerable  light  on  the  mode  in 
which  the  natural  development  of  the 
pelvis  is  effected.  It  is  difficult  to 
diaofnose,  inasmuch  as  there  is  no 
apparent  external  deformity,  and 
probably  it  has  never,  in  fact,  been 
detected  before  delivery.  It  has  a 
very  serious  influence  on  labor ;  Litz- 
mann  found  that  out  of  28  cases  of 
this  deformity,  22  died  in  their  first 
labors,  and  5  more  in  subsequent  de- 
liveries. The  prognosis,  therefore,  is 
very  formidable,  and  renders  a  knowl- 
edge of  this  distortion,  rare  though  it  be,  of  importance. 

Its  essential  characteristic  is  flattening  and  want  of  development 
of  one  side  of  the  pelvis,  associated  with  anchylosis  of  the  correspond- 
ing sacro-iliac  synchondrosis.  The  latter  is  probably  always  present, 
and  it  seems  to  be  most  generally  a  congenital  malformation.  The 
lateral  half  of  the  sacrum  on  the  same  side,  and  the  entire  innominate 
bone  are  much  atrophied.  The  promontory  of  the  sacrum  is  directed 
towards  the  diseased  side,  and  the  symphysis  pubis  is  pushed  over 
towards  the  healthy  side. 

The  main  agent  in  the  production  of  this  deformity  is  the  absence 
of  the  sacro-iliac  joint,  which  prevents  the  proper  lateral  expansion  of 


Obliquely  Contracted  Pelvis.     (After 
Duacan.) 


380  LABOR. 

the  pelvic  brim  on  that  side,  and  allows  the  counter-pressure,  through 
the  feiTiLir,  to  push  in  the  atrophied  os  innominatum  to  a  much  greater 
extent  than  usual.  The  chief  diminution  in  the  length  of  the  pelvic 
diameter  is  between  the  ilio-pectineal  eminence  of  the  affected,  side 
and  the  healthy  sacro-iliac  joint;  while  the  oblique  diameter  between 
the  anchjdosed  joint  and  the  healthy  os  innominatum  is  of  normal 
length. 

Narrowhvj  of  the  Transverse  Diameter. — Transverse  contraction  of 
the  pelvic  brim  is  very  much  less  common  than  narrowing  of  the 
conjugate  diameter.  It  most  frequently  depends  on  backward  curv- 
ature of  the  lower  parts  of  the  spinal  column,  in  consequence  of 
disease  of  the  vertebrae.  This  form  of  deformed  pelvis  is  generally 
known  as  the  hyphotic.  The  effect  of  the  spinal  curvature  is  to  drag 
the  promontory  of  the  sacrum  backwards,  so  that  it  is  high  up  and 
out  of  reach.  By  this  means  the  antero-posterior  diameter  of  the 
brim  is  increased,  while  the  transverse  is  leFsened  ;  the  relative  pro- 
portion between  the  two  is  thus  reversed.  While  the  upper  propor- 
tion of  the  sacrum  is  displaced  backwards,  its  lower  end  is  projected 
forward,  so  that  the  antero-posterior  diameters  of  the  cavity  and 
outlet  are  considerably  diminished.  The  ischial  tuberosities  are  also 
nearer  to  each  other,  and  the  pubic  arch  is  narrowed.  Obstruction 
to  delivery  will  be  chiefly  met  with  at  the  lower  parts  and  outlet  of 
the  pelvic  cavity;  for,  although  the  transverse  diameter  of  the  brim 
is  narrowed,  there  is  generally  sufficient  space  for  the  passage  of  the 
head. 

EoLerfs  Pelvis. — Another  form  of  transversely  contracted  pelvis 
is  known  as  RoherCs  pelvis  (Fig.  133),  having  been  first  discovered  by 

Eobert,  of  Coblentz.     It  is  in  fact  a 
pjg  233_  double  obliquely  t3ontracted  pelvis, 

depending  on  anchylosis  of  both 
sacro-iliac  joints,  and  consequent 
defective  development  of  the  innom- 
inate bones.  The  shape  of  the 
pelvic  brim  is  markedly  oblong,  and 
the  sides  of  the  pelvis  are  more  or 
less  parallel  with  each  other.  The 
outlet  is  also  much  conti^acted  trans- 
versely. The  amount  of  obstruction 
is  very  great,  so  that,  according  to 
Schroeder,  out  ■  of  7  well-authenti- 
„,    „      T^    VI  «iv     1  r.    *     *  J       cated  cases  the  Ctesarean  section  was 

Robert  s  or  Donblo  Obliquely  Contracted  .  ^ 

Pelvis.  (After  Duncan.)  rCCjUired  Ul   5. 

Deformity  from  Old-standing  Hip- 
joint  Disease. — Another  cause  of  transverse  deformity,  occasionally 
met  with,  is  luxation  of  the  head  of  the  femur,  depending  on  old- 
standing  joint  disease.  The  head  of  the  femur,  in  this  case,  presses 
on  the  innominate  bone  at  the  site  of  dislocation,  and  the  result  is 
that  the  iliac  fossa  on  the  affected  side,  or  both  if  the  accident  hap- 
pens on  both  sides,  is  pushed  inwards,  the  transverse  diameter  of 
the  brim  being  lessened.    The  tuberosity  of  the  ischium  is,  however, 


DEFORMITIES    OF    THE    PELVIS. 


381 


Fig.  134. 


projected  outwards,  so  that  the  outlet  of  the  pelvis  is  increased  rather 
than  diminished. 

Deformity  frovi  Tumors^  Fraciures^  etc. — Obstruction  of  the  pelvic 
cavity  from  exostosis  or  other  forms  of  tumors  growing  from  the  bones 
is  of  groat  rarity  (Fig,  134).  It 
may,  however,  produce  very  serious 
dystocia.  Several  curious  ex- 
amples are  collected  in  Mr.  Wood's 
article  on  the  pelvis,  in  some  of  which 
the  obstruction  was  so  great  as  to 
necessitate  the  Cagsareau  section.^ 
Some  of  these  growths  were  true 
exostoses  ;  and,  according  to  Stadt- 
feldt,^  these  are  commonly  found  in 
pelves  that  are  otherwise  contracted; 
others  osteo-sarcoraatous  tumors 
attached  to  the  pelvic  bones,  most 
generally  the  upper  part  of  the 
sacrum ;  and  others  were  malignant. 
In  some  cases  spiculas  of  bone  have 
developed  about  the  linea  ilio-pec- 
tinea  or  other  parts  of  the  pelvis, 
which  may  not  be  sufficient  to  pro- 
duce obstruction,  but  which  may 
injure  the  uterus,  or  even  the  foetal 
head,  when  they  are  pressed  upon  them.  Irregular  projections 
ma}''  also  arise  from  the  callus  of  old  fractures  of  the  pelvic  bones. 
All  such  cases  defy  classification,  and  dift'er  so  greatly  in  their  extent, 
and  in  their  effect  on  labor,  that  no  rules  can  be  laid  down  for  them, 
and  each  must  be  treated  on  its  own  merits. 

Effects  of  Contracted  Pelvis  in  Labor. — The  effects  of  pelvic  con- 
tractions on  labor  vary,  of  course,  greatly  with  the  amount  and 
nature  of  the  deformity ;  but  they  must  always  give  rise  to  anxiety, 
and,  in  the  graver  degrees,  they  produce  the  most  serious  difficulties 
we  have  to  contend  with  in  the  whole  range  of  obstetrics. 

Nature  of  Uterine  Action  in  Pelvic  Deformity. — In  the  lesser  degrees, 
in  which  the  proportion  between  the  presenting  part  and  the  pelvis 
is  only  slightly  altered,  we  may  observe  little  abnormal  beyond  a 
greater  intensity  of  the  pains,  and  some  protraction  of  the  labor.  It 
is  generally  observed  that  the  uterine  contractions  are  strong  and 
forcible  in  cases  of  this  kind,  probably  because  of  the  increased 
resistance  they  have  to  contend  against ;  and  this  is  obviously  a 
desirable  and  conservative  occurrence,  which  may,  of  itself,  suffice 
to  overcome  the  difficulty.  The  first  stage,  however,  is  not  infre- 
quentl}^  prolonged,  and  the  pains  are  ineffective,  for  the  head  does 


Bony  Growtli  from  Sacrum  Obstructing  the 
Pelvic  Cavity. 


['  Pelvic  exostosis  has  Tieen  the  obstacle  to  delivery  in  eight  American  Cesarean 
cases.  One  woman  was  operated  npon  three  times,  and  died  after  the  last  operation. 
Five  of  the  children  w(ire  born  alive.  Four  women  recovered.  Two  died  after  labors 
of  three  days  each,  and  one,  of  two. — Ed.] 

2  Obstetrical  Journ.,  .July,  1879. 


382  LABOR. 

not  refidilj  engage  in  the  brim,  the  uterus  is  more  mobile  than  in 
ordinary  labors,  and  it  probably  acts  at  a  disadvantage. 

Rlslito  the  Mother. — In  the  more  serious  cases,  the  mother  is  sub- 
jected to  many  risks,  directly  proportionate  to  the  amount  of  obstruc- 
tion and  the  length  of  the  labor.  The  long-continued  and  excessive 
uterine  action,  produced  by  the  vain  endeavors  to  push  the  child 
through  the  contracted  pelvic  canal,  the  more  or  less  prolonged  con- 
tusion and  injury  to  which  the  maternal  soft  parts  are  necessarily 
subjected  (not  unfrequently  ending  in  inflammation  and  sloughing 
with  all  its  attendant  dangers),  and  the  direc-t  injury  which  may  be 
inflicted  by  the  measures  we  are  compelled  to  adopt  for  aiding  de- 
livery (such  as  the  forceps,  turning,  craniotomy,  or  Csesarean  sec- 
tion), all  tend  to  make  the  prognosis  a  matter  of  grave  anxiety. 

Risk  to  the  Child. — Nor  are  the  dangers  less  to  the  child ;  and  a 
very  large  proportion  of  still-births  will  always  be  met  with.  The 
infantile  mortality  may  be  traced  to  a  variety  of  causes,  the  most 
important  being  the  protraction  of  the  labor,  and  the  continuous 
pressure  to  which  the  presenting  part  is  subjected.  For  this  reason, 
even  in  cases  in  which  the  contraction  is  so  slight  that  the  labor  is 
terminated  by  the  natural  powers,  it  has  been  estimated  that  1  out 
of  every  5  children  is  still-born;  and  as  the  deformity  increases  in 
amount,  so,  of  course,  does  the  prognosis  to  the  child  become  more 
unfavorable. 

Frequent  Occurrence  of  Prolapse  of  the  Cord. — Prolapse  of  the 
umbilical  cord  is  of  'nqt^  frequent  occurrence  in  cases  of  pelvic  de- 
formity, the  tendency  to  this  accident  being  traceable  to  the  fact  oi 
the  head  not  entering  and  occupying  the  upper  strait  of  the  pelvis 
as  in  ordinary  labors,  and  thus  leaving  a  space  through  which  the 
cord  may  descend.  So  frequently  is  this  complication  met  with  in 
pelvic  deformity  that  Stanesco^  found  it  had  happened  as  often  as  59 
times  in  414  labors ;  and  when  the  dangers  of  prolapsed  funis  are 
added  to  those  of  protracted  labors,  it  is  hardly  a  matter  of  surprise 
that  the  occurrence  should,  under  such  circumstances,  almost  always 
prove  fatal  to  the  child. 

Injury  to  Child^s  Head. — The  head  of  the  child  is  also  liable  to 
injury  of  a  more  or  less  grave  character  from  the  compression  to 
which  it  is  subjected,  especially  by  the  promontory  of  the  sacrum. 
Independently  of  the  transient  effects  of  undue  pressure  (temporary 
alteration  of  the  shape  of  the  bones  and  bruising  of  the  scalp),  there 
is  often  met  with  a  more  serious  depression  of  the  bones  of  the  skull, 
produced  by  the  sacral  promontory.  This  is  most  marked  in  cases 
in  which  the  head  has  been  forcibly  dragged  past  the  projecting  bone 
by  the  forceps,  or  after  turning.  The  amount  of  depression  varies 
with  tlie  degree  of  contraction;  but  sometimes,  were  it  not  for  the 
yielding  of  the  bones  of  the  foetal  skull  in  this  Avay,  delivery,  with- 
out lessening  the  size  of  the  head  by  perforation,  would  be  impossi- 
ble. Such  depressions  are  found  at  the  spot  immediately  opposite 
the  promontory,  generally  at  the  side  of  the  skull  near  the  junction 

I  Op.  cit.  p.  94. 


DEFORxMITIES    OF    THE    PELVIS.  383 

of  the  frontal  and  parietal  bones.  Sometimes  there. is  a  slight  per- 
manent mark,  but  more  often  the  depression  disappears  in  a  few 
days.  The  prognosis  to  the  child  is,  however,  grave,  when  the  con- 
traction has  been  sufficient  to  indent  the  skull;  for  it  has  been  found 
that  50  per  cent,  of  the  children  thus  marked  died  either  immediately 
or  shortly  after  labor.^ 

Course  of  Labor. — The  means  which  nature  takes  to  overcome  these 
difficulties  are  well  worthy  of  study,  and  there  are  certain  peculiari- 
ties in  the  mechanism  of  delivery  when  pelvic  deformities  exist, 
which  it  is  of  importance  to  understand,  as  they  guide  us  in  deter- 
mining the  proper  treatment  to  adopt. 

Frequency  of  Malpresentation. — Mai  presentations  of  the  foetus  are 
of  much  more  frequent  occurrence  than  in  ordinary  labors;  partly 
because  the  head  does  not  engage  readily  in  the  brim,  but,  remaining 
free  above  it,  is  apt  to  be  pushed  away  by  the  uterine  contractions, 
and  partly  because  of  the  frequent  alteration  of  the  axis  of  the 
uterine  tumor.  The  pendulous  condition  of  the  abdomen  in  cases 
of  pelvic  deformity  is  often  very  obvious,  so  that  the  fundus  is 
sometimes  almost  in  a  line  with  the  cervix,  and  thus  transverse  or 
other  abnormal  positions  are  very  frequently  met  with.  It  is  to  be 
noted,  however,  that  Ave  cannot  regard  breech  presentations  as  so 
unfavorable  as  in  ordinary  labors,  for  the  pressure  from  the  con- 
tracted pelvis  is  less  likely  to  be  injurious  when  applied  to  the  body 
than  to  the  head  of  the  child ;  and  indeed,  as  we  shall  presently  see, 
the  artificial  production  of  these  presentations  is  often  advisable  as  a 
matter  of  choice. 

Mechanism  of  Delivery  in  Head  Presentations. — The  mode  in  which 
the  head  passes  naturally  through  a  contracted  pelvis  is  in  some 
respects  different  from  the  ordinary  mechanism  of  delivery  in  head 
presentations,  and  has  been  carefully  worked  out  by  Spiegelberg, 
and  other  German  obstetricians. 

The  means  which  nature  adopts  to  overcome  the  difficulty  are  dif- 
ferent in  cases  in  which  there  is  a  marked  narrowing  of  the  conju- 
gate diameter  of  the  brim,  and  in  those  in  which  there  is  a  generally 
contracted  pelvis. 

In  Contracted  Brim. — In  the  former,  and  more  common  deformity, 
when  the  head  enters  the  brim,  in  consequence  of  the  resistance  it 
meets  with,  the  expelling  power  of  the  uterus  acts  more  on  the  ante- 
rior part  of  the  head  than  in  ordinary  cases,  the  chin  becomes  in 
some  degree  separated  from  the  sternum,  and  the  anterior  fontanelle 
descends  somewhat  lower  than  the  posterior.  At  this  stage,  on  ex- 
amination, it  will  be  found — supposing  we  have  to  do  with  a  case  in 
which  the  occiput  points  to  the  left  side  of  the  pelvis — that  the  ante- 
rior fontanelle  is  lower  than  the  posterior,  and  to  the  right,  the  bi- 
temporal diameter  of  the  head  is  engaged  in  the  conjugate  diameter 
of  the  brim  (as  the  smallest  diameter  of  the  skull,  there  is  manifest 
advantage  in  this),  the  bi-parietal  diameter  and  the  largest  portion 
of  the  head  points  to  the  left  side.     The  sagittal  suture  will  be  felt 

'  Schroeder,  op.  cit.  p.  256. 


88J:  LABOR. 

running  across  in  tlie  transverse  diameter  of  the  brim,  but  nearer  to 
the  sacrum,  the  head  being  placed  obliquely.  As  the  head  is  forced 
down  by  the  uterine  contractions,  the  parietal  bone,  which  is  resting 
on  the  promontory,  is  pushed  against  it,  so  that  the  sagittal  suture 
is  forced  more  into  the  true  transverse  diameter  of  the  pelvic  brim, 
and  approaches  nearer  to  the  pubis.  The  next  step  is  the  depression 
of  the  head,  the  occiput  undergoing  a  sort  of  rotation  on  its  trans- 
verse axis,  so  that  it  reaches  a  plane  below  the  brim.  When  this  is 
accomplished,  the  rest  of  the  head  readily  passes  the  obstruction. 
The  forehead  now  meets  with  the  resistance  of  the  pelvic  walls,  the 
posterior  fontanelle  descends  to  a  lower  level,  and,  as  the  cavity  of 
the  pelvis  in  cases  of  antero-posterior  contraction  of  the  brim  is 
generally  of  normal  dimensions,  the  rest  of  the  labor  is  terminated 
in  the  usual  way. 

In  generally  Contracted  Pelvis. — In  the  generally  contracted  pelvis 
the  head  enters  the  brim  with  the  posterior  fontanelle  lowest,  and  it 
is  after  it  has  engaged  in  it  that  the  resistance  to  its  progress  becomes 
manifest.  The  result  is,  therefore,  an  exaggeration  of  what  is  met 
with  in  ordinarj^  cases.  The  resistance  to  the  anterior  or  longer  arm 
of  the  lever  is  greater  than  that  to  the  occipital  or  shorter ;  and, 
therefore,  the  flexion  of  the  head  becomes  very  marked.  The  pos- 
terior fontanelle  is  consequently  unusually  depressed,  and  the  ante- 
rior quite  out  of  reach.  So  the  head  is  forced  down  as  a  wedge,  and 
its  further  progress  must  depend  upon  the  amount  of  contraction. 
If  this  be  not  too  great  the  anterior  fontanelle  eventually  descends, 
and  delivery  is  completed  in  the  usual  way.  Should  the  contraction 
be  too  much  to  permit  of  this,  the  head  becomes  jammed  in  the 
pelvis,  and  diminution  of  its  size  may  be  essential. 

In  cases  of  deformity  of  the  conjugate  diameter,  combined  with 
general  contraction  of  the  pelvis,  the  mechanism  partakes  of  the  pe- 
culiarities of  both  these  classes,  to  a  greater  or  less  extent,  in  propor- 
tion to  the  preponderance  of  one  or  other  species  of  deformity. 

Diagnosis. — It  rarely  happens  that  deformities  of  the  pelvis,  except 
of  the  gravest  kind,  are  suspected  before  labor  has  actually  com- 
menced ;  and,  therefore,  we  are  not  often  called  upon  to  give  an  opin- 
ion as  to  the  condition  of  the  pelvis  before  delivery.  Should  we  be 
so,  there  are  various  circumstances  which  may  aid  us  in  arriving  at 
a  correct  conclusion.  Prominent  among  them  is  the  history  of  the 
patient  in  childhood.  If  she  is  known  to  have  suffered  from  rickets 
in  early  life,  more  especially  if  the  disease  has  left  evident  traces  in 
deformities  of  the  limbs,  or  in  a  dwarfed  and  stunted  growth,  or  in 
curvature  of  the  spine,  there  will  be  strong  presumptive  evidence  of 
pelvic  deformity;  a  markedly  pendulous  state  of  the  abdomen  may 
also  tend  to  confirm  the  suspicion.  Nothing  short  of  a  careful  ex- 
amination of  the  pelvis  itself  will,  however,  clear  up  the  point  with 
certainty  ;  and,  even  by  this  means,  to  estimate  the  precise  degree  of 
deformity  with  accuracy  requires  considerable  skill  and  practice. 
The  ingenuity  of  practitioners  has  been  much  exercised,  it  might 
perhaps  be  justly  said,  wasted,  in  the  invention  of  various  more  or 
less  complicated  pelvimeters  for  aiding  us  in  obtaining  the  desired 


DEFORMITIES    OF    THE    PELVIS.  385 

object.  It  is,  however,  prettv  generally  admitted  by  all  accoucheurs, 
that  the  hand  forms  the  best  and  most  reliable  instrument  for  this 
purpose,  at  any  rate  as  regards  the  interior  of  the  pelvis;  although  a 
pair  of  callipers,  such  as  Baudelocque's  well-known  instrument,  is 
essential  for  accurately  determining  the  external  measurements.  The 
objections  to  all  internal  pelvimeters,  even  those  most  simple  in  their 
construction,  are  their  cost  and  complexity,  and  the  imj^ossiljility  of 
using  them  without  pain  or  injury  to  the  patient. 

External  Measurements. — It  was  formerly  thought  that  by  meas- 
uring the  distance  between  the  spinous  processes  of  the  sacrum  and 
the  symphysis  pubis,  and  subtracting  from  it  what  we  judge  to  be 
the  thickness  of  the  bones  and  soft  parts,  we  might  arrive  at  an  ap- 
proximate estimate  of  the  measurement  of  the  conjugate  diameter  of 
the  pelvic  brim.  It  is  now  admitted  that  this  method  can  never  be 
depended  on,  and  that,  taken  by  itself,  it  is  practically  useless.  A 
change  in  the  relative  length  of  other  external  measurements  of  the 
pelvis  is,  however,  often  of  great  value  in  showing  the  existence  of 
deformity  mternally,  although  not  in  judging  of  its  amount.  The 
measurements  which  are  used  for  this  purpose  are  between  tlie 
anterior  superior  spines  of  the  ilia,  and  between  the  centres  of  their 
crests,  averaging  respectively  10  and  11  inches.  According  to  Spie- 
gelberg  these  measurements  may  give  one  of  three  results. 

1.  Both  may  be  less  than  they  ought  to  be,  but  the  relation  of  the 
one  to  the  other  remains  unchanged. 

2.  That  between  the  crests  is  not,  or  is  at  most  Yerj  little,  dimin- 
ished, but  that  between  the  spines  is  increased. 

3.  Both  are  diminished,  but  at  the  same  time  their  mutual  relation 
is  not  normal,  the  distance  between  the  spines  being  as  long,  if  not 
longer,  than  that  between  the  crests. 

No.  1  denotes  a  uniformly  contracted  pelvis.  ISTo.  2,  a  pelvis 
simply  contracted  in  the  conjugate  diameter  of  the  brim,  and  not 
otherwise  deformed.  No.  3,  a  pelvis  with  narrowed  conjugate  and 
also  uniformly  contracted,  as  in  the  severe  type  of  rachitic  deformity. 
IF,  however,  both  these  measurements  are  of  average  length,  and  the 
distance  between  the  crests  is  about  one  inch  greater  than  between 
the  spines,  the  pelvis  is  normal. 

Besides  the  above  some  information  may  be  obtained  by  the 
measurement  of  the  external  conjugate  diameter,  which  averages 
7|-  inches.  This  may  be  taken  by  placing  one  point  of  the  callipers 
in  the  depression  below  the  spine  of  the  last  lumbar  vertebra,  the 
other  at  the  centre  of  the  upper  edge  of  the  symphysis  pubis.  If  the 
measurement  be  distinctly  below  the  average,  not  more,  for  example 
than  6.3  in.,  we  may  conclude  that  there  is  a  narrowing  of  the  an^ 
tero-posterior  diameter  of  the  brim,  the  extent  of  which  we  must 
endeavor  to  ascertain  by  other  means. 

For  the  purpose  of  making  these  measurements  Baudelocque's 
corapas  d' epaisseur  can  be  used,  or  Dr.  Lazarewitch's  elegant  universal 
pelvimeter,  which  can  be  adopted  also  for  internal  pelvimetry ;  but, 
in  the  absence  of  these  special  contrivances,  an  ordinary  pair  of  calli- 
})ers,  such  as  are  used  by  carpenters,  can  be  made  to  answer  the 
desired  object. 


386 


LABOR. 


Greeulialgh's  Pelvimeter. 


Internal  Measurements. — These  external  measurements  must  be 
corroborated  by  internal,  chiefly  of  the  antero-posterior  diameter,  by 

which  alone  we  can  estimate  the 
amount  of  the  deformity.  We  en- 
deavor to  find,  in  the  first  place, 
the  length  of  the  diagonal  conju- 
gate, between  the  lower  edge  of 
the  symphysis  pubis  and  the  prom- 
ontory of  the  sacrum,  which  aver- 
ages about  half  an  inch  more  than 
the  true  conjugate.  This  is  best 
done  by  placing  the  patient  on  her 
back,  with  the  hips  well  raised. 
The  index  and  middle  fina-er  of 
the  right  hand  are  then  intro- 
duced into  the  vagina,  and  the 
perineum  is  pressed  steadily  back- 
wards, so  as  to  overcome  the  re- 
sistance it  ofl'ers.  If  the  tip  of  the 
second  finger  can  reach  the  prom- 
ontory of  the  sacrum,  the  radial 
side  of  the  first  finger  is  raised  so 
as  to  touch  the  lower  edge  of  the 
pubis,  A  mark  is  made  with  the 
nail  of  the  index  of  the  left  hand 
on  that  part  of  the  examining  finger  which  rests  under  the  symphysis, 
and  then  the  distance  from  this  to  the  tip  of  the  finger,  less  half  an 
inch,  may  be  taken  to  indicate  the  measurement  of  the  true  conjugate 
of  the  brim.  Various  pelvimeters  are  meant  to  make  the  same  meas- 
urements, such  as  Lumley  Earle's,  Lazarewitch's,  which  is  similar  in 
principle,  and  Yan  fluevel's  ;  the  best  and  simplest,  I  think,  is  that 
invented  by  Dr.  Greenhalgh  (Fig.  135).  It  consists  of  a  movable 
rod,  attached  to  a  flexible  band  of  metal  which  passes  around  the 
palm  of  the  examining  hand.  At  the  distal  end  of  the  rod  is  a  curved 
portion,  which  passes  over  the  radial  edge  of  the  index  finger.  The 
examination  is  made  in  the  usual  way,  and  when  the  point  of  the 
finger  is  resting  on  the  promontory  of  the  sacrum,  the  rod  is  with- 
drawn until  it  is  arrested  by  the  posterior  surface  of  the  symphysis, 
the  exact  measurement  of  the  diagonal  conjugate  being  then  read  off 
on  the  scale. 

It  is  to  be  remembered  that  this  procedure  is  useless  in  the  slighter 
degrees  of  contraction,  on  Avhich  the  promontory  of  the  sacrum  cannot 
be  easily  reached.  Dr.  Ramsbotham  proposed  to  measure  the  con- 
jugate by  spreading  out  the  index  and  middle  fingers  internally,  the 
tip  of  one  resting  on  the  promontory,  the  other  behind  the  symphysis 
pubis ;  and  then  drawing  them,  in  the  same  position,  and  measuring 
the  distance  between  them.  This  manoeuvre  I  believe  to  be  imprac- 
ticable. 

"Whenever,  in  actual  labor,  w^e  wish  to  ascertain  the  condition  of 
the  pelvis  accurately,  the  patient  should  be  anaesthetized,  and  the 


DEFORMITIES    OF    THE    PELVIS.  387 

whole  hand  introduced  into  the  vagina  (which  could  not  otherwise 
be  done  without  causing  great  pain),  and  the  proportions  of  the 
pelvis,  and  the  relations  of  the  head  to  it,  thoroughly  explored  ;  and, 
if  what  has  been  said  as  to  the  mechanism  of  delivery  in  these  cases 
be  borne  in  mind,  this  may  aid  us  in  determining  the  kind  of  de- 
formity existing.  In  this  way  contractions  about  the  outlet  of  the 
pelvis  can  also  be  pretty  generally  made  out. 

Mode  of  Diagnosing  the  Oblique  Pelvis. — The  obliquely  contracted 
pelvis  cannot  be  determined  by  any  of  these  methods,  but  certain 
external  measurements,  as  Naegele  has  pointed  out,  will  readily 
enable  us  to  recognize  its  existence.  It  will  be  found  that  measure- 
ments, which  in  the  healthy  pelvis  ought  to  be  equal,  are  unequal  in 
the  obliquely  distorted  pelvis.  The  points  of  measurement  are  chiefly  ; 
1.  From  the  tuberosity  of  the  ischium  on  one  side  to  the  posterior 
superior  spine  of  the  ilium  on  the  other  ;  2.  From  the  anterior 
superior  iliac  spine  on  the  one  side  to  the  posterior  superior  on  the 
opposite;  3.  From  the  trochanter  major  of  one  side  to  the  posterior 
superior  iliac  spine  on  the  other ;  4.  From  the  lower  edge  of  the 
symphysis  pubis  to  the  posterior  superior  iliac  spine ;  5.  From  the 
spinous  process  of  the  last  lumbar  vertebra  to  the  anterior  superior 
spine  of  the  ilium  on  either  side. 

If  these  measurements  differ  from  each  other  by  half  an  inch  to  an 
inch,  the  existence  of  an  oblique  deformed  pelvis  may  be  safely 
diagnosed.  The  diagnosis  can  be  corroborated  by  placing  the  patient 
in  the  erect  position,  and  letting  fall  two  plumb  lines,  one  from  the 
spines  of  the  sacrum,  the  other  from  the  symphysis  pubis.  In  a 
healthy  pelvis  these  will  fall  in  the  same  plane,  but  in  the  oblique 
pelvis  the  anterior  line  will  deviate  considerably  towards  the  un- 
affected side. 

Treatment.— l^he  proper  management  of  labor  in  contracted  pelvis 
is,  even  up  to  this  time,  one  of  the  most  vexed  questions  in  midwifery, 
notwithstanding  the  immense  amount  of  discussion  to  which  it  has 
given  rise ;  and  the  varying  opinions  of  accoucheurs  of  equal  expe- 
rience afford  a  strongproof  of  the  difficulties  surrounding  the  subject. 
This  remark  applies,  of  course,  only  to  the  lesser  degrees  of  deformity, 
in  which  the  birth  of  a  living  child  is  not  hopeless.  When  the  antero- 
posterior diameter  of  the  brim  measures  from  2f  to  3  inches,  it  is 
universally  admitted  that  the  destruction  of  the  child  is  inevitable, 
unless  the  pelvis  be  so  small  as  to  necessitate  the  performance  of  the 
Csesarean  section.  But  when  it  is  between  3  inches  and  the  normal 
measurement,  the  comparative  merits  of  the  forceps,  turning  and 
the  induction  of  premature  labor,  form  a  fruitful  theme  for  discus- 
sion. With  one  class  of  accoucheurs  the  forceps  is  chiefly  advocated, 
and  turning  admitted  as  an  occasional  resource  when  it  has  failed  ; 
and  this  indeed,  speaking  broadly,  may  be  said  to  have  been  the 
general  vievy  held  in  this  country.  More  recently  we  find  German 
authorities  of  eminence,  such  as  Schroeder  and  Sj^iegelberg,  giving 
turning  the  chief  place,  and  condemning  the  forceps  altogether  in 
contracted  pelvis,  or  at  least,  restricting  its  use  within  very  narrow 
limits.      More  strangely  still  we  find,  of  late,  that  the  induction  of 


388  LABOR. 

premature  labor,  on  the  origination  and  extension  of  v/hicli  British 
accoucheurs  have  always  prided  themselves,  is  placed  without  the 
pale,  and  spoken  of  as  injurious  and  useless  in  reference  to  pelvic 
deformities.  To  see  our  way  clearly  amongst  so  many  conflicting 
opinions  is  by  no  means  an  easy  task,  and  perhaps  we  may  best  aid 
in  its  accomplishment  by  considering  separately  the  three  operations 
in  so  far  as  they  bear  on  this  subject,  and  pointing  out  briefly  what 
can  be  said  for  and  against  each  of  them. 

The  Forceps. — In  England  and  in  France  it  is  pretty  generally 
admitted  that  in  the  slighter  degrees  of  contraction  the  most  reliable 
means  of  aiding  the  patient  is  by  the  forceps.  It  should  be  remem- 
bered that  the  operation,  under  such  circumstances,  is  always  much 
more  serious  than  in  ordinary  labors  simply  delayed  from  uterine 
inertia,  when  there  is  ample  room,  and  the  head  is  in  the  cavity  of 
the  pelvis  ;  for  the  blades  have  to  be  passed  up  very  high,  often  when 
the  head  is  more  or  less  movable  above  the  brim,  and  much  more 
traction  is  likely  to  be  required.  For  these  reasons  artificial  assist- 
ance, when  pelvic  deformity  is  suspected,  is  not  to  be  lightly  or 
hurriedly  resorted  to.  Nor  fortunately  is  it  always  necessary ;  for 
if  the  pains  be  sufficiently  strong,  and  the  contraction  not  too  great 
to  prevent  the  head  engaging  at  all,  after  a  lapse  of  time  it  will  be- 
come so  moulded  in  the  brim  as  to  pass  even  a  considerable  obstruc- 
tion. In  all  cases,  therefore,  sufficient  time  must  be  given  for  this; 
and  if  no  suspicious  symptoms  exist  on  the  part  of  the  mother — no 
elevation  of  temperature,  dryness  of  the  vagina,  rapid  pulse,  and  the 
like,  and  the  foetal  heart-sounds  continue  to  be  normal — labor  may 
be  allowed  to  go  on  for  some  hours  after  the  rupture  of  the  mem- 
branes, so  as  to  give  nature  a  chance  of  completing  the  delivery. 
When  this  seems  hopeless,  the  intervention  of  art  is  called  for. 

Cases  Suitable  for  the  Forcei^s.- — The  forceps  is  generally  considered 
to  be  applicable  in  all  degrees  of  contraction,  from  the  standard 
measurement,  down  to  about  Scinches  in  the  conjugate  of  the  brim. 
There  can  be  no  doubt  that,  in  such  cases,  traction  with  the  forceps 
often  enables  us  to  effect  delivery,  when  the  natural  efforts  have 
proved  insufficient,  and  holds  out  a  very  fair  hope  of  saving  the 
child.  Out  of  17  cases  in  which  the  high  forceps  operation  was  re- 
sorted to  for  pelvic  deformity,  reported  by  Stanesco,  in  13  living 
children  were  born.  If  the  length  of  the  labor,  and  the  long-con- 
tinued comprets.'on  to  which  the  child  has  been  subjected,  be  borne 
in  mind,  this  result  must  be  considered  very  favorable. 

Ohjections  that  have  been  raised  to  the  Forceps. — What  are  the  ob- 
jections which  have  been  brought  against  the  operation?  These  have 
been  principall}'"  made  by  Schroeder  and  other  German  writers. 
They  are,  chiefly  the  difficulty  of  passing  the  instrument ;  the  risk 
of  injuring  the  maternal  structures;  and  the  supposition  that,  as  the 
blades  must  seize  the  head  by  the  forehead  and  occiput,  their  com 
pressive  action  will  diminish  its  longitudinal  and  increase  its  trans- 
verse diameter  (which  is  opposed  to  the  contracted  part  of  the  brim), 
and  so  enlarge  the  head  just  where  it  ought  to  be  smallest.  There 
is  little  doubt  that  these  writers  much  exaggerate  the  compressive 


DEFORMITIEvS    OF    THE    PELVIS. 


389 


Fig.  136. 


power  of  the  forceps.  Certainly  with  those  generally  used  in  this 
country,  any  disadvantage  likely  to  accrue  from  this  is  more  than 
counterbalanced  by  the  traction  on  the  head ;  and  the  fact,  that 
minor  degrees  of  obstruction  can  be  thus  overcome,  with  safety  both 
to  the  mother  and  child,  is  abundantly  proved  by  the  numberless 
cases  in  wdiich  the  forceps  have  been  used. 

It  is  not  equally  Suitable  in  all  kinds  of  Deformity. — It  is  very  likely 
that  the  forceps  do  not  act  equally  well  in  all  cases.  When  the  head 
is  loose  above  the  brim  ;  when  the  contraction  is  chiefly  limited  to 
the  antero-posterior  diameter,  and  there  is  abundance  of  room  at  the 
sides  of  the  pelvis  for  the  occiput  to  occupy  after  version;  and  when, 
as  is  usual  in  these  cases,  the  anterior  fontanelle  is  depressed  and  the 
head  lies  transversely  across  the  brim,  it  is  probable  that  turning 
may  be  the  safer  operation  for  the  mother,  and  the  easier  performed. 
When,  on  the  other  hand,  the  head  has  engaged  in  the  brim,  and  has 
become  more  or  less  impacted,  it  is  obvious  that  version  could  not  be 
performed  without  pushing  it  back,  which  may  neither  be  eas\^  nor 
safe.  In  the  generally  contracted  pelvis,  in  wliich  the  head  enters  in 
an  exaggerated  state  of  flexion  and  lies  obliquely,  the  posterior  fon- 
tanelle being  much  depressed,  the  forceps  are  more  suitable. 

Mechanical  Advantage  of  Turning  in  certain  Cases. — The  special 
reasons  why  version,  sometimes  succeeds  when  the  forceps  fails,  or 
why  it  may  be  elected  from  the  first  as  a 
matter  of  choice,  have  been  by  no  one  better 
pointed  out  than  by  Sir  James  Simpson. 
Altliough  the  operation  was  performed  by 
many  of  the  older  obstetricians,  its  revival 
in  modern  times,  and  the  clear  enunciation  of 
its  principles,  can  undoubtedly  be  traced  to 
his  writings.  He  points  out  that  the  head  of 
the  child  is  shaped  like  a  cone,  its  narrowest 
portion  the  base  of  the  cranium  (Fig.  136,  5/>), 
measuring,  on  an  average,  from  |  to  f  of  an 
inch  less  than  the  broadest  portion  (Fig.  136, 
aa),  viz.,  the  bi-parietal  diameter.  In  ordi- 
nary head  presentations  the  latter  part  of  the 
head  has  to  pass  first ;  but  if  the  feet  are 
brought  down,  the  narrow  apex  of  the  cra- 
nial cone  is  brought  first  into  apposition  with 
the  contracted  brim,  and  can  be  no  more 
easily  draivn  through  than  the  broader  base 
can  be  pushed  through  by  the  uterine  con- 
tractions. JSTor  is  this  the  onl}^  advantage, 
for  after  turning  the  narrower  bi-temporal 
diameter  (Fig.  137,  hh) — which  measures,  on 
an  average,  half  an  inch  less  than  the  bi- 
parietal  (Fig.  137,  aa) — is  brought  into  con- 
tact with  the  contracted  conjugate,   while  the       Showing  the  greater  breadth  of 

broader  bi-parietal  lies  in  the  comparativelv       '^'^  ^'"P''"®'^^  Diameter  of 

•1  i_  l_^  •  ^  o  .^  ^     •      /-r-i-        -.  ^,-^^  t'le   Fcetal    Cranium.      ^After 

Wide  space  at  the  side  of  the  pelvis  (Fig.  138).       simpson.) 


Section  of  FoBtalCrauium,  show- 
ing its  Conical  Form. 


390  LABOR. 

These  mechanical  considerations  are  sufficiently  obvious,  and  fully 
explain  the  success  which  has  often  attended  the  performance  of  the 
operation. 

Limits  of  the  Operation. — It  is  generally  admitted  that  it  may  be 
possible,  for  the  reasons  just  mentioned,  to  deliver  a  living  child  by 
turning,  through  a  pelvis  contracted  beyond  the  point  which  would 
permit  of  a  living  cliild  being  extracted  by  the  forceps.  Many  ob- 
stetricians believe  that  it  is  possible  to  deliver  a  living  child  by  turn- 
ino-  in  a  pelvis  contracted  even  to  the  extent  of  2f  inches  in  the 
conjugate  diameter.  Barnes  maintains  that,  although  an  unusually 
compressible  head  may  be  drawn  through  a  pelvis  contracted  to  3 
inches,  the  chance  of  the  child  being  born  alive  under  such  circum- 
stances must  necessarily  be  small,  and  that  from  3^  inches  to  the 
normal  size  must  be  taken  as  the  proper  limits  of  the  operation. 

Fig.  138. 


Showinc  the  greater  space  for  the  Bi-parielal  Diameter  at  the  side  of  the  Pelvis  in  certain 
cases  of  Deformity.     (After  Simpson.) 

That  delivery  is  often  possible  by  turning,  after  the  forceps  and 
the  natural  powers  have  failed,  and  when  no  other  resource  is  left 
but  the  destruction  of  the  child,  must,  I  think,  be  admitted  by  all ; 
for  the  records  of  obstetrics  are  full  of  such  cases.  To  take  one  ex- 
ample only.  Dr.  Braxton  Hicks^  records  four  cases  in  which  the  for- 
ceps were  tried  unsuccessfully,  in  all  of  which  version  was  used, 
three  of  the  children  being  born  alive.  Here  are  the  lives  of  three 
children  rescued  from  destruction,  within  a  short  period,  in  the 
practice  of  one  man;  and  a  fact  like  this  would,  of  itself,  be  ample 
justification  of  the  attempt  to  deliver  by  turning,  when  the  child  was 
known  to  be  alive,  and  other  means  had  failed.  The  possibility  that 
craniotomy  may  still  be  required  is  no  argument  against  the  opera- 
tion ;  for  although  perforation  of  the  after-coming  head  is  certainly 
not  so  easy  as  perforation  of  a  presenting  head,  it  is  not  so  much 
more  difficult  as  to  justify  the  neglect  of  an  experiment  by  which  it 
may  possibly  be  altogether  avoided. 

Comparative  Estimate  of  the  Two  Operatio7is. — The  original  choice 
of  turning  is  a  more  difficult  question  to  decide.  My  own  impression 
is  that  the  use  of  the  forceps  will  generally  be  found  to  be  preferable. 
An  exception  should,  I  think,  be  made  for  those  cases  in  which  the 

1  Guy's  Hosp.  Rep.  1870. 


DEFORMITIES    OF    THE    PELVIS.  391 

head  refuses  to  enter  the  brim,  and  cannot  be  sufficiently  steadied 
by  external  pressure  to  admit  of  an  easy  application  of  the  instru- 
ment. Under  these  circumstances  increasing  experience  leads  me  to 
prefer  turning  as  decidedly  the  simpler  and  safer  operation,  and  the 
passage  of  the  head  through  the  contracted  brim  can  be  very  mate- 
rially°facilitated  by  strong  pressure  from  above,  as  has  been  so  well 
pointed  out  by  Goodell.^ 

An  argument  used  by  Martin,  of  Berhn,^  in  reference  to  the  two 
operations,  should  not  be  lost  sight  of,  as  it  seems  to  be  a  valid  reason 
for  giving  a  preference  to  the  forceps.  He  points  out  that  moulding 
may  safely  be  applied  for  hours  to  the  vertex ;  but  that  when  pres- 
sure is  applied  to  the  important  structures  about  the  base  of  the 
brain,  as  after  turning,  moulding  cannot  be  continued  beyond  five 
minutes  witliout  proving  fatal.  This,  however,  is  no  reason  Avhy 
turning  should  not  be  used  after  the  forceps  and  the  natural  efforts 
have  proved  ineffectual. 

Craniotomy  or  the  Caesar ean  Section  is  required. — When  the  con- 
traction is  below  3  inches  in  the  conjugate,  or  when  the  forceps  and 
turnins;  have  f^iiled,  no  resource  is  left  but  the  destruction  of  the 
foetus,  or  the  Cassarean  section. 

The  induction  of  premature  lahor  as  a  means  of  avoiding  the  risks 
of  delivery  at  term,  and  of  possibly  saving  the  life  of  the  child,  must 
now  be  studied.  The  established  rule,  in  this  country,  is,  that  in  all 
cases  of  pelvic  deformity,  the  existence  of  which  has  been  ascertained 
either  by  the  experience  of  former  labors,  or  by' accurate  examina- 
tion of  the  pelvis,  labor  should  be  induced  previous  to  the  full  period 
so  that  the  smaller  and  more  compressible  head  of  the  premature 
foetus  may  pass,  Avliere  that  of  the  foetus  at  term  could  not.  The 
gain  is  a  double  one,  partly  the  lessened  risk  to  the  mother,  and 
partly  the  chance  of  saving  the  child's  life. 

The  practice  is  so  thoroughly  recognized  as  a  conservative  and 
judicious  one,  that  it  might  be  deemed  unnecessary  to  argue  in  its 
favor,  were  it  not  that  some  most  eminent  authorities  have  of  late 
years  tried  to  show,  that  it  is  better  and  safer  to  the  mother  to  leave 
the  labor  to  come  on  at  term ;  and  that  the  risk  to  the  child  is  so 
great  in  artificially  induced  labor  as  to  lead  to  the  conclusion  that 
the  operation  should  be  altogether  abandoned,  except,  perhaps,  in 
the  extreme  distortion  in  which  the  C«sarean  section  might  other- 
wise be  necessary.  Prominent  amongst  those  who  hold  these  views 
are  Spiegelberg  and  Litzmann,  and  they  have  been  supported,  in  a 
modified  form,  by  Matthews  Duncan.  Spiegelberg^  tries  to  show, 
by  a  collection  of  cases  from  various  sources,  that  the  results  of  in- 
duced labor  in  contracted  pelvis  are  much  more  unfavorable  than 
when  the  cases  are  left  to  nature ;  that  in  the  latter  the  mortality  of 
the  mothers  is  Q.%  per  cent.,  and  of  the  children  28.7  per  cent.,  whereas 
in  the  former  the  maternal  deaths  are  15  per  cent,,  and  the  infantile 
66.9  per  cent.      Litzmann*  arrives    at    not  very  dissimilar  results, 

'  Amer.  .Jonrn.  of  Obst.,  vol.  viii.  2  Mon.  f.  Geburt.  1867. 

>  Arch.  f.  Gyn.  b.  1.  s.  1.  ■»  lb.  b.  ii.  s.  169. 


392  LABOR. 

namely,  6.9  per  cent,  of  the  mothers  and  20.3  per  cent,  of  the  children 
in  contracted  pelvis  at  term,  and  14.7  per  cent,  of  the  mothers  and 
55.8  per  cent,  of  the  children,  in  artificially  induced  premature  labor. 

If  these  statistics  were  reliable,  inasmuch  as  they  show  a  very 
decided  risk  to  the  mother,  there  might  be  great  force  in  the  argu- 
ment that  it  would  be  better  to  leave  the  cases  to  run  the  chance  of 
delivery  at  term.  It  is,  however,  very  questionable  whether  they 
can  be  taken,  in  themselves,  as  being  sufficient  to  settle  the  question. 
The  fallacy  of  determining  such  points  by  a  mass  of  heterogeneous 
cases,  collected  together  without  a  careful  sifting  of  their  histories, 
has  over  and  over  again  been  pointed  out ;  and  it  would  be  easy 
enough  to  meet  them  by  an  equal  catalogue  of  cases  in  which  the 
maternal  mortality  is  almost  nil.  The  results  of  the  practice  of 
many  authorities  are  given  in  Churchill's  work,  where  we  find,  for 
example,  that  out  of  46  cases  of  Merriman's,  not  one  proved  fatal. 
The  same  fortunate  result  happened  in  62  cases  of  Earabotham's. 
Plis  conclusion  is,  that  "  there  is  undoubtedly  some  risk  incurred  by 
the  mother,  but  not  more  than  by  accidental  premature  labor,"  and 
this  conclusion,  as  regards  the  mother,  is  that  which  has  long  ago 
been  arrived  at  by  the  majority  of  British  obstetricians,  who  un- 
doubtedly have  more  experience  of  the  operation  than  those  of  any 
other  nation.  With  regard  to  the  child,  even  if  the  German  statis- 
tics be  taken  as  reliable,  they  would  hardly  be  accepted  as  contra- 
indicating  the  operation,  inasmuch  as  it  is  intended  to  save  the  mother 
from  the  dangers  of  the  more  serious  labor  at  term,  and,  in  many 
cases,  to  give  at  least  a  chance  to  the  child,  whose  life  would  other- 
wise be  certainly  sacrificed.  The  result,  moreover,  must  depend  to  a 
great  extent  on  the  method  of  operation  adopted,  for  many  of  the 
plans  of  indacing  labor  recommended  are  certainly,  in  themselves, 
not  devoid  of  danger  both  to  the  mother  and  the  child.  It  may,  I 
think,  be  admitted,  as  Duncan  contends,*  that  the  operation  has 
been  more  often  performed  than  is  absolutely  necessary,  and  that  the 
higher  degrees  of  pelvic  contraction  are  much  more  uncommon  than 
has  been  supposed  to  be  the  case.  That  is  a' very  valid  reason  for 
insisting  on  a  careful  and  accurate  diagnosis,  but  not  for  rejecting  an 
operation  which  has  so  long  been  an  established  and  favorite  re- 
source. 

Delermination  of  Period  for  Indv.cJn(]  Lcd)or. — When  the  induc- 
tion of  labor  has  been  determined  on,  the  precise  period  at  which  it 
should  be  resorted  to  becomes  a  question  for  anxious  consideration, 
for  the  longer  it  is  delayed  the  greater,  of  course,  are  the  dangers  for 
the  child.  Many  tables  have  been  constructed  to  guide  us  on  this 
point,  which  are  not,  on  the  whole,  of  so  much  service  as  they  might 
appear  to  be,  on  account  of  the  difficulty  of  determining  with  minute 
accuracy  the  amount  of  contraction.  The  following,  however,  which 
is  drawn  up  by  Kiwisch,  may  serve  for  a  guide  in  settling  this  ques- 
tion : — ■ 

t  Ediu.  Med.  Journ.,  July,  1873,  p.  339. 


HEMORRHAGE 

BEFORE    DELIVERY. 

Inches. 

Lines. 

-pubic  diameter 

if- 

2  and 

6  or    7 

induce 

labor  at 

30th  wee 

2    " 

8  "    9 

31st       " 

2    " 

10  "  11 

32d        " 

3    " 

— 

33d        " 

3    " 

1 

33d 

3    " 

2  "    3 

34th      " 

3    " 

4  "    5 

3.0th      " 

3    " 

5  "    6 

3Gth      " 

393 


In  cases  of  moderate  deformity,  when  labor  pains  Lave  been  in- 
duced, the  farther  progress  of  tiie  case  may  be  left  to  nature ;  but 
in  the  more  maked  cases,  as  in  those  below  3  inches,  it  will  often 
be  found  necessary  to  assist  delivery  by  turning  or  by  the  forceps, 
the  former  being  here  specially  useful,  on  account  of  the  extreme 
pliability  of  the  head,  and  the  facility  with  which  it  may  be  drawn 
through  the  contracted  brim.  By  thus  combining  the  two  operations 
it  may  be  quite  possible  to  secure  the  birth  of  a  living  child  even  in 
pelves  very  considerably  deformed. 

Production  of  Abortion  in  extreme  Deformity. — When  the  contraction 
is  so  great  as  to  necessitate  the  induction  of  the  labor  before  the  sixth 
month,  or,  in  other  words,  before  the  child  has  reached  a  viable  age, 
it  would  be  preferable  to  resort  to  a  very  early  production  of  abor- 
tion. The  operation  is  then  indicated,  not  for  the  sake  of  the  child, 
but  to  save  the  mother  from  the  deadly  risk  to  which  she  would 
otherwise  be  subjected.  As  in  these  cases,  the  mother  alone  is  con- 
cerned, the  operation  should  be  performed  as  soon  as  we  have  posi- 
tively determined  the  existence  of  pregnancy.  No  object  can  be 
gained  by  waiting  until  the  development  of  the  child  is  advanced  to 
any  extent,  and  the  less  the  foetus  is  developed,  the  less  will  be  the 
pain  and  risks  the  mother  has  to  undergo.  There  is  no  amount  of 
deformity,  however  great,  in  which  w^e  could  not  succeed  in  bringing 
on  miscarriage  by  some  of  the  numerous  means  at  our  disposal;  and, 
in  spite  of  Dr.  Eadford's  objections,  who  maintains  that  the  obstetri- 
cian is  not  justified  in  sacrificing  the  life  of  a  human  being  more  than 
once,  when  the  mother  knows  that  she  cannot  give  birth  to  a  viable 
child,  there  are  few  practitioners  who  would  not  deem  it  their  duty 
to  spare  the  mother  the  terrible  dangers  of  the  Csesarean  section. 


CHAPTEE    XIII. 

HEMOERHAGE  BEFORE  DELIVERY  :    PLACENTA  PREVIA. 

The  hemorrhages  which  are  the  result  of  an  abnormal  situation 

of  the  placenta,  partially  or  entirely,  over  the  internal  os  uteri,  have 

formed  a  most  fruitful  theme  for  discussion.     The  causes  producing 

the  abnormal  placental  site,  the  sources  of  the  blood,  and  the  causes 

26 


394  LABOR. 

of  its  escape,  the  means  adopted  by  nature  for  its  arrest,  and  the 
proper  treatment,  have,  each  and  all  of  them,  been  the  subject  of 
endless  controversies,  which  are  not  jet  by  any  means  settled.  It 
must  be  admitted,  too,  that  the  extreme  importance  of  the  subject 
amply  justifies  the  attention  which  has  been  paid  to  it ;  for  there  is 
no  obstetric  complication  more  apt  to  produce  sudden  and  alarming 
effects,  and  none  requiring  more  prompt  and  scientific  treatment. 

By  placenta  p)r8evia  we  mean  the  insertion  of  the  placenta  at  the 
lower  segment  of  the  uterine  cavity,  so  that  part  of  it  is  situated, 
wholly  or  partially,  over  the  internal  os  uteri.  In  the  former  case 
there  is  complete  or  central  placental  presentation,  in  the  latter  an 
incomplete  or  ^marginal  presentation. 

Causes. — The  causes  of  this  abnormal  placental  site  are  not  fully 
Tinderstood.  It  was  supposed  by  Tyler  Smith  to  depend  on  the  ovale 
not  having  been  impregnated  until  it  had  reached  the  lower  part  of 
the  uterine  cavity.  Cazeaux  suggests  that  the  uterine  mucous  mem- 
brane is  less  swollen  and  turgid  than  when  impregnation  occurs  at 
the  more  ordinary  place,  and  that,  therefore,  it  offers  less  obstruction 
to  the  descent  of  the  ovule  to  the  lower  part  of  the  uterine  cavity. 
An  abnormal  size,  or  unusual  shape,  of  the  uterine  cavity  may  also 
favor  the  descent  of  the  impregnated  ovule ;  the  former  probably 
explains  the  fact,  that  placenta  prasvia  more  generally  occurs  in 
women  who  have  borne  several  children.^  These  are  merely  interest- 
ing speculations  having  no  practical  value,  the  fact  being  undoubted 
that,  in  a  not  inconsiderable  number  of  cases — estimated  by  Johnson 
and  Sinclair  as  1  out  of  573 — the  placenta  is  grafted  partially  or 
entirely  over  the  uterine  orifice. 

History. — Placenta  prsevia  was  not  unknown  to  the  older  writers, 
who  believed  that  the  placenta  had  originally  been  situated  at  the 
fundus,  from  which  it  had  accidentally  fallen  to  the  lower  part  of 
the  uterus.  Portal,  Levret,  Eoederer,  and  especially  our  own  country- 
man Pigby,  where  among  those  Avhose  observations  tended  to  improve 
the  state  of  obstetrical  knowledge  as  to  its  real  nature.  To  Pigby 
we  owe  the  term  "  unavoidable  hemorrhage^''''  as  a  synonym  for  placenta 
prsevia,  and  as  distinguishing  hemorrhage  from  this  source  from  that 
resulting  from  separation  of  the  placenta  at  its  more  usual  position, 
termed  by  him,  in  contra-distinction,  "  accidental  hem.orrhage.''''  These 
names,  adopted  by  most  writers  on  the  subject,  are  obviously  mis- 
leading, as  they  assume  an  essential  distinction  in  the  etiology  of  the 
hemorrhage  in  the  two  classes  of  cases,  which  is  not  alway  warranted. 

'  [In  the  statistical  tables  of  Trask'  and  King, 2  which  coUectivel}'  furnish  the  cases 
of  245  women,  the  number  of  whose  pregnancies  is  noted,  we  find  that  the  largest 
number  of  placentre  prrevire  occurred  in  the  second  pregnancy,  after  which  they  grad- 
ually declined.  Thus  we  find  23  placental  presentations  in  primiparse,  49  in  second 
labors,  31  in  third,  30  in  fourth,  and  29  in  fifth.  One-fifth  then  of  all  the  cases  were 
second  pregnancies  ;  and  nearly  one-third,  first  and  second.  The  sixth  pregnancies 
in  both  Trask's  and  King's  record,  are  almost  exactly  the  same  as  the  proportion  in 
primiparse.  The  belief  in  the  greater  frequency,  after  several  pregnancies  is,  there- 
fore, not  well  founded. — Ed.] 

[1  Prize  essay  of  Dr.  James  D.  Trask.  of  N.  Y.,  Trans.  Am.  Med.  Ass.  lSo:'i,  p.  66.S.] 
[2  Statistics  of  Placenta  Prsevia,  collected  from  the  practice  of  physicians  in  the  State  of  Indiana 
ly  Dr.  Enoch  W.  King,  of  Galena,  Ind.,  1879,  Svo.  pp.  50,  cases,  11-.] 


HEMORRHAGE    BEFORE    DELIVERY.  395 

It  is  of  the  utmost  importance  to  a  right  understanding  of  the 
nature  and  treatment  of  placenta  prsevia  that  we  should  fully  under- 
stand the  source  of  the  hemorrhage,  and  the  manner  of  its  produc- 
tion ;  but  we  shall  be  able  to  discuss  this  subject  better  after  a 
desci'iption  of  the  symptoms. 

Sym'ptoms. — Although  the  placenta  must  occup}''  its  unusual  site 
from  the  earliest  period  of  its  formation,  it  rarely  gives  rise  to  appre- 
ciable symptoms  before  the  last  three  months  of  utero-gestation.  It 
is  far  from  unlikely,  however,  that  such  an  abnormal  situation  of  the 
placenta  may  produce  abortion  in  the  earlier  months,  the  site  of  its 
attachment  passing  unobserved. 

Sudden  Flow  of  Blood. — The  earliest  symptom  which  causes  suspi- 
cion is  the  sudden  occurrence  of  hemorrhage,  without  any  appreciable 
cause.  The  amount  of  blood  lost  varies  considerabl\^  In  some  cases 
the  first  hemorrhage  is  comparatively  slight,  and  is  soon  spontaneously 
arrested ;  but,  if  the  case  be  left  to  itself,  the  flow  after  a  lapse  of 
time — it  may  be  a  few  days,  or  it  may  be  weeks — again  commences 
in  the  same  unexpected  way,  and  each  successive  hemorrhage  is  more 
profuse.  The  losses  show  themselves  at  different  periods.  They 
rarely  begin  before  the  end  of  the  sixth  month,  more  often  nearer 
the  full  period,  and  sometimes  not  until  labor  has  actually  com- 
menced. The  hemorrhage  very  often  coincides  with  what  would 
have  been  a  menstrual  period  ;  doubtless  on  account  of  the  physio- 
logical congestion  of  the  uterine  organs  then  present.  Should  the 
first  loss  not  show  itself  until  at  or  near  the  full  time,  it  may  be 
tremendous,  and  a  few  moments  may  suffice  to  place  the  patient's 
life  in  jeopardy.  Indeed  it  may  be  safely  accepted  as  an  axiom,  that 
once  hemorrhage  has  occurred,  the  patient  is  never  safe  ;  for  excessive 
losses  maj^  occur  at  any  moment  without  warning,  and  when  assist- 
ance is  not  at  hand.  It  often  happens  that  premature  labor  comes 
on  after  one  or  more  hemorrhages. 

In  any  case  of  placenta  prtevia,  when  labor  has  commenced, 
whether  premature  or  at  the  full  time,  the  hemorrhage  may  become 
excessive,  and  with  each  pain  fresh  portions  of  placenta  may  be  de- 
tached, and  fresh  vessels  torn  and  left  open.  Under  these  "circum- 
stances the  blood  often  escapes  in  greater  quantity  with  each  suc- 
cessive pain,  and  diminishes  in  the  intervals.  This  has  long  been 
looked  upon  as  a  diagnostic  mark  by  which  we  can  distinguish  be- 
tween the  so-called  "unavoidable"  and  "accidental"  hemorrhage; 
in  the  latter  the  flow  being  arrested  during  the  pains.  The  distinc- 
tion, however,  is  altogether  fallacious..  The  tendency  of  uterine 
contraction  in  placenta  previa,  as  in  all  other  forms  of  uterine 
hemorrhage,  is  to  constrict  the  vessels  from  which  the  blood  escapes, 
and  so  to  lessen  the  flow.  The  apparently  increased  flow  during  the 
pains  depends  on  the  pains  forcing  out  blood  which  has  already 
escaped  from  the  vessels.  In  one  way  up  to  a  certain  point,  the 
pains  do  favor  hemorrhage,  by  detaching  fresh  portions  of  placenta; 
but  the  actual  loss  takes  place  chiefly  during  the  intervals,  and  not 
during  the  continuance  of  contraction. 


396  LABOR. 

Results  of  Vaginal  Examination. — On  vaginal  examination,  if  the 
OS  be  sufficiently  open  to  admit  the  finger,  which  it  generally  is  on 
account  of  the  relaxation  produced  by  the  loss  of  blood,  we  shall 
almost  always  be  able  to  feel  some  portion  of  presenting  placenta. 
If  it  be  a  central  implantation,  we  shall  find  the  upper  aperture  of 
the  cervix  entirely  covered  by  a  thick,  boggy  mass,  which  is  to  be 
distinguished  from  a  coagulum  by  its  consistence,  and  by  its  not 
breaking  down  under  the  pressure  of  the  finger.  Through  the  pla- 
cental mass  we  may  feel  the  presenting  part  of  the  foetus ;  but  not 
as  distinctly  as  when  there  is  no  intervening  substance.  In  partial 
placental  presentations  the  bag  of  membranes,  and  above  it  the  head 
or  other  presentation,  will  be  found  to  occupy  a  part  of  the  circle  of 
the  OS,  the  rest  being  covered  by  the  edge  of  the  placenta.  In  mar- 
ginal presentations  we  may  only  be  able  to  make  out  the  thickened 
edge  of  the  after-birth,  projecting  at  the  rim  of  the  os.  If  the  cer- 
vix be  high,  and  the  gestation  not  advanced  to  term,  these  points 
may  not  be  easy  to  make  out,  on  account  of  the  difficulty  of  reaching 
the  cervix ;  and,  as  accurate  diagnosis  is  of  the  utmost  importance, 
it  is  proper  to  introduce  two  fingers,  or  even  the  whole  hand,  so  as 
thoroughly  to  explore  the  condition  of  the  parts.  The  lower  portion 
of  the  uterine  ovoid  may  be  observed  to  be  more  than  usually  thick 
and  fleshy  ;  and  Gendrin  has  pointed  out  that  ballottement  cannot  be 
made  out.  The  accuracy  of  our  diagnosis  may  be  confirmed,  in 
doubtful  cases,  by  finding  that  the  placental  bruit  is  heard  over  the 
lower  part  of  the  uterine  tumor. 

Dr.  Wallace^  has  suggested  that  vaginal  auscultation  may  be  ser- 
viceable in  d.agnosis,  and  states  that,  by  means  of  a  curved  wooden 
stethoscope,  the  placental  bruit  may  be  heard  with  startling  distinct- 
ness. This  is,  however,  a  manoeuvre  that  can  hardly  be  generally 
carried  out  in  actual  practice. 

The  Source  of  Hemorrhaye.- — It  is  now  generally  admitted  by  au- 
thorities that  the  immediate  source  of  the  hemorrhage  is  the  lacerated 
utero-placental  vessels.  Only  a  few  years  ago  Sir  James  Simpson 
advocated  with  his  usual  energy,  the  theory,  sustained  by  his  pre- 
decessor, Dr.  Hamilton,  that  the  chief,  if  not  the  only,  source  of 
hemorrhage  was  the  detached  portion  of  the  placenta  itself.  He 
argued  that  the  blood  flowed  from  the  portion  of  the  placenta  which 
was  still  adherent  into  that  which  was  separated,  and  escaped  from 
the  surface  of  the  latter ;  and  on  this  supposition  he  based  his  prac- 
tice of  entirely  separating  the  placenta,  having  observed  that,  in 
many  cases  in  which  the  after-birth  had  been  expelled  before  the 
child,  the  hemorrhage  had  ceased.  The  fact  of  the  cessation  of  the 
hemorrhage,  when  this  occurs,  is  not  doubted ;  but  Simpson's  expla- 
nation is  contested  by  most  modern  writers,  prominent  among  whom 
is  Barnes,  who  has  devoted  much  study  to  the  elucidation  of  the  sub- 
ject. He  points  out  that  the  stoppage  of  the  hemorrhage  is  not  due 
to  the  separation  of  the  placenta,  but  to  the  preceding  or  accompany- 
ing contraction  of  the  uterus,  which  seals  up  the  bleeding  vessels, 

I  Edin.  Med.  Journ.,  Not.  1872. 


HEMORRHAGE    BEFORE    DELIVERY.  397 

just  as  it  does  in  other  forms  of  hemorrhage.  The  site  of  the  loss 
was  actually  demonstrated  by  the  late  Dr.  Mackenzie  in  a  series  of 
experiments,  in  which  he  partially  detached  the  placenta  in  pregnant 
bitches,  and  found  that  the  blood  flowed  from  the  walls  of  the  uterus, 
and  not  from  the  detached  surface  of  the  placenta.  The  arrange- 
ment of  the  large  venous  sinuses,  opening  as  they  do  on  the  uterine 
mucous  membrane,  favors  the  escape  of  blood  when  they  are  torn 
across ;  and  it  is  from  them,  possibly  to  some  extent  also  from  the 
uterine  arteries,  that  the  blood  comes,  just  as  in  post-partum  hemor- 
rhage, when  the  whole,  instead  of  a  part,  of  the  placental  side  is 
bared. 

Causes  of  HemorrluKje. — Various  explanations  have  been  given  of 
the  causes  of  the  hemorrhage.     For  long  it  was  supposed  to  depend 
on  the  gradual  expansion  of  the  cervix  during  the  latter  mouths  of 
pregnancy,  which  separated  the  abnormally  placed  placenta.     It  has 
been  seen,  however,  that  this  shortening  of  the  cervix  is  apparent 
only,  and  that  the  cervical  canal  is  not  taken  up  into  the  uterine 
cavity  during  gestation,  or,  at  all  events,  only  during  the  last  week 
or  so.     This,  therefore,  cannot  be  admitted  as  an  explanation  of  pla- 
cental separation.     Jacquemier  proposed  another  theory  which  has 
been  adopted  by  Cazeaux,     He  maintains  that  during  the  first  six 
months  of  utero-gestation  the  superior  portion  of  the  uterus  is  more 
especially  developed,  as  shown  by  the  pyriform  shape  of  the  fundus 
during  the  time;  and  that,  as  the  placenta  is  usually  attached  in  that 
situation,  and  then  attains  its  maximum  of  development,  its  relations 
to  its  attachments  are  undisturbed.     Daring  the  last  three  months  of 
pregnancy,  on  the  contrary,  the  lower  segment  of  the  uterus  develops 
more  than  the  upper,  while  the  placenta  remains  nearly  vStationary 
in  size;  the  inevitable  result  being  a  loss  of  proportion  between  the 
cervix  and  the  placenta,  and  the  detachment  of  the  latter.     There 
arc  various  objections  which  can  be  brought  against  this  theory; 
the  most  important  being  that  there  is  no  evidence  at  all  to  show 
that  the  lower  segment  of  the  uterus  does  expand  more  in  proportion 
than  the  upper  during  the  latter  months  of  pregnancy.     Barnes's 
theory  is  based  on  the  supposition  that  the  loss  of  relation  between 
the  uterus  and  placenta  is  caused  by  excess  of  growth  on  the  part 
of  the  placenta  itself  over  that  of  the  cervix,  which  is  not  adapted 
for  its  attachment.     The  placenta,  on  this  hypothesis,  grows  away 
from  the  site  of  its  attachment,  and  hemorrhage  results.     It  will  be 
observed  that  neither  this  theory,  nor  that  propounded  by  Jacque- 
mier, are  readily  reconcilable  with  the  fact  that  hemorrhage  fre- 
quently does  not  begin  until  labor  has  commenced  at  term.    Inasmuch 
as  the  loss  of  relation  between  the  placenta  and  its  attachments, 
which  they  both  presuppose,  must  exist  in  every  case  of  placenta 
prsevia,  hemorrhage  should  alwaj^s  occur  during  some  part  of  the 
last  three  months  of  pregnancy.     Matthews  Duncan^  has  recently  in- 
vestigated the  whole  subject  at  length,  and  maintains  that  the  hemor- 
rhages are  accidental,  not  unavoidable,  being  due  to  precisely  similar 

1  Edin,  Med.  Journ.,  Nov.  1873,  and  Brit.  Med.  Jouni.,  Nov.  1873. 


398  LABOR. 

causes  are  those  which  give  rise  to  the  occasional  hemorrhages  when 
the  placenta  is  normally  placed.  The  abnormal  situation  of  the  pla- 
centa, of  course,  renders  these  causes  more  apt  to  operate ;  but  in 
their  action  he  believes  them  to  be  precisely  similar  to  those  of  acci- 
dental hemorrhage,  properly  so  called.  Separation  of  the  placenta 
from  expansion  of  the  cervix,  he  believes  to  be  the  cause  of  hemor- 
rhage after  labor  has  begun,  and  then  it  may  strictly  be  called  una 
voidable:  but  hemori'hage  is  comparatively  seldom  so  produced 
during  the  continuance  of  pregnancy.  "There  are,"  says  Duncan, 
"  four  ways  in  which  this  kind  of  hemorrhage  may  occur  : — 

"  1.  By  the  rupture  of  a  utero-placental  vessel  at  or  about  the  in- 
ternal OS  uteri. 

"2.  By  the  rupture  of  a  marginal  utero-placental  sinus  within  the 
area  of  spontaneous  premature  detachment,  when  the  placenta  is  in- 
serted not  centrally  or  covering  the  internal  os,  but  with  a  margin  at 
or  near  the  central  os. 

"3.  By  partial  separation  of  the  placenta  from  accidental  causes, 
such  as  a  jerk  or  fall. 

"4.  By  a  partial  separation  of  the  placenta,  the  consequence  of 
uterine  pains  producing  a  small  amount  of  dilatation  of  the  internal 
OS.  Such  cases  may  be  otherwise  described  as  instances  of  miscar- 
riage commencing,  but  arrested  at  a  very  early  stage." 

I  see  no  reason  to  doubt  the  possibility  of  hemorrhage  being  due, 
in  many  cases,  to  the  first  three  causes,  and  in  its  production  it  would 
strictly  resemble  accidental  hemorrhage.  The  fourth  heading  refers 
the  hemorrhage  to  partial  separation,  in  consequence  of  commencing 
dilatation  of  the  cervix,  but  it  explains  the  dilatation  by  the  suppo- 
sition of  commencing  miscarriage.  This  latter  hypothesis  seems  to 
be  as  needless  as  those  Avhich  presuppose  a  want  of  relation  between 
the  placenta  and  its  attachments.  We  know  that,  quite  independ- 
ently of  commencing  miscarriage,  uterine  contractions  are  constantly 
occurring  during  the  continuance  of  pregnanc3\  There  is  reason  to 
suppose  that  these  contractions  do  not  affect  the  cervical,  as  well  as 
the  fundal  portions  of  the  uterus ;  and  in  cases  in  which  the  placenta 
is  situated  partially  or  entirely  over  the  os,  one  or  more  stronger 
contractions  than  usual  may,  at  any  moment,  produce  laceration  of 
the  placental  attachments  in  that  neighborhood. 

Pathological  Changes  in  the  Placenta. — A  careful  examination  of 
the  placenta  may  show  pathological  changes  at  the  site  of  separation, 
such  as  have  been  described  by  Gendrin,  Simpson,  and  other  writers. 
They  probably  consist  of  thrombosis  in  the  placental  cotyledons,  and 
effused  blood-clots,  variously  altered  and  discolorized,  according  to 
the  lapse  of  time  since  separation  took  place.  Changes  occur  in  the 
portion  of  the  placenta  overlying  the  os  uteri,  whether  separation 
has  occurred  or  not.  There  may  be  atrophy  of  the  placental  struc- 
ture in  this  situation,  as  well  as  changes  of  form,  such  as  complete 
or  partial  separation  into  two  lobes,  the  junction  of  which  overlies 
the  OS  uteri.' 

•  Sinelius,  Arch.  Gen.  de  Med.,  vol.  ii.  1861. 


HEMORRHAGE    BEFORE    DELIVERY.  399 

Natural  Termination  when  Placenta  'presents. — The  history  of  de- 
livery, if  left  to  nature,  is  specially  worthy  of  study,  as  guiding  to 
proper  rules  of  treatment.  It  sometimes  happens,  when  the  pains 
are  very  strong  and  the  delivery  rapid,  that  labor  is  completed  with- 
out any  hemorrhage  of  consequence.  "Although,"  says  Cazeaux, 
"hemorrhage  is  usually  considered  to  be  inevitable  under  such  cir- 
cumstances, yet  it  may  not  appear  even  during  the  labor;  and  the 
dilatation  of  the  os  uteri  may  be  effected  without  the  loss  of  a  drop 
of  blood."  Again,  Simpson  conclusively  showed,  that  when  the 
placenta  was  expelled  before  the  birth  of  the  child,  all  hemorrhage 
ceased. 

Barnes's  theory  of  placenta  pnevia,  which  has  been  pretty  gene- 
rally adopted,  explains  satisfactorily  both  these  classes  of  cases. 

He  describes  the  uterine  cavity  as  divisible  into  three  zones  or 
regions.  When  the  placenta,  is  situated  in  the  upper  or  middle  of 
these  zones,  no  separation  or  hemorrhage  need  occur  during  labor. 
When,  however,  it  is  situated  partially  or  entirely  in  the  lower  or 
cervical  zone,  the  expansion  of  the  cervixduring  labor  must  produce 
more  or  less  separation,  and  consequent  loss  of  blood.  As  soon  as 
the  previous  portion  of  the  placenta  is  sufficiently  separated,  provided 
contraction  of  the  uterine  tissue  be  present  to  seal  up  the  mouths  of 
the  vessels,  hemorrhage  no  longer  takes  place.  The  placenta  may 
not  be  entirely  detached,  but  no  further  hemorrhage  occurs,  in  con- 
sequence of  the  remaining  portion  being  engrafted  on  the  uterus 
beyond  the  region  of  unsafe  attachment. 

In  the  former,  then,  of  these  classes  of  cases,  the  absence  of  hemor- 
rhage is  explained  on  this  theory,  by  the  pains  being  sufficiently 
rapid  and  strong  to  complete  the  separation  of  the  placental  attach- 
ment from  the  lower  cervical  zone  before  flooding  had  taken  place  ; 
in  the  latter,  it  ceases,  not  necessarily  because  the  entire  placenta  is 
expelled,  but  because  of  its  detachment  from  the  area  of  dangerous 
implantation. 

The  amount  of  cervical  expansion  required  for  this  purpose  varies 
in  different  cases.  Dr.  Duncan^  estimates  the  limit  of  the  spontaneous 
detaching  area  to  be  a  circle  of  4J  inches  diameter,  and  that,  after 
the  cervix  has  expanded  to  that  extent,  no  further  separation  or 
hemorrhage  takes  place.  To  admit  of  the  passage  of  a  full-sized 
head,  Barnes  estimates  that  expansion  to  about  a  circle  of  6  inches 
diameter  is  necessary;  on  the  other  hand  he  has  sometimes  observed 
"that  the  hemorrhage  has  completely  stopped  when  the  os  uteri  had 
opened  to  the  size  of  the  rim  of  a  wineglass,  or  even  less." 

It  will  be  seen  then  that  in  this,  as  in  every  other  form  of  puer- 
peral hemorrhage,  the  tendency  of  uterine  contraction  is  to  check 
the  hemorrhage ;  and  that,  provided  the  pains  are  sufficiently  ener- 
getic, nature  may  be  capable  of  stopping  the  flooding  without  arti- 
ficial aid.  It  is  but  rarely,  however,  that  she  can  be  trusted  for  the 
purpose  ;  and  we  shall  presently  see  that  these  theoretical  views 
have  an  important  practical  bearing  on  the  subject  of  treatment. 

'  Obst.  Trans.,  vol.  xv.. 


400  LABOR. 

Prognosis. — The  prognosis  to  both  the  mother  and  child  is  cer- 
tainly grave  in  all  cases  of  placenta  prtevia.  Eead,  in  his  treatise 
on  placenta  prasvia,  estimates  the  maternal  mortality,  from  the  statis- 
tics of  a  large  number  of  cases,  as  1  in  4 J  cases,  and  Churchill  as  1 
in  3.  This  is  unquestionably  too  high  an  estimate,  and  based  on 
statistics  the  accuracy  of  which  cannot  be  relied  on.  The  mortality 
will,  of  course,  greatly  depend  on  the  treatment  adopted.  Doubtless, 
if  cases  were  left  to  nature,  the  result  would  be  quite  as  unfavorable 
as  Read  supposes.  But  if  properly  managed,  much  more  successful 
results  may  safely  be  anticipated.  Out  of  64  cases,  recorded  by 
Barnes,  the  deaths  were  6,  or  1  in  10|.  Under  any  circumstances 
the  risks  to  the  mother  are  very  great.  Churchill  estimates  that 
more  than  half  the  children  are  lost.  The  reasons  for  the  great 
danger  to  the  child  are  very  obvious,  subjected  as  it  is  to  the  risk  of 
asphyxia  from  the  loss  of  the  maternal  blood,  and  from  its  respira- 
tion l^eing  carried  on  during  labor  by  a  placenta  which  is  only  par- 
tially attached  ;  many  children  also  perish  from  prematurity,  or  from 
mal-presentation. 

Treatment. — Whenever,  in  the  latter  months  of  pregnancy,  a  sudden 
hemorrhage  occurs,  the  possibility  of  placenta  previa  will  naturally 
suggest  itself;  and,  by  a  careful  vaginal  examination,  which  under 
such  circumstances  should  always  be  insisted  on,  the  existence  of 
this  complication  will  generally  be  readily  ascertained.  It  is  seldom 
that  the  os  is  not  sufficiently  dilated  to  enable  us  to  satisfy  ourselves 
when  the  placenta  is  presenting. 

Is  it  justifiable  to  alloiu  the  Pregnancy  to  Continue? — The  first  ques- 
tion that  will  arise  is.  are  we  justified  in  temporizing,  using  means 
to  check  the  hemorrhage,  and  allowing  the  pregnancy  to  continue  ? 
This  is  the  course  which  has  generally  been  recommended  in  works 
on  midwifery.  We  are  told  to  place  the  patient  on  a  hard  mattress, 
not  to  heat  or  overburden  her  with  clothes,  to  keep  her  absolutely  at 
rest,  to  have  the  room  cool  and  Avell-aired,  to  apply  cold  cloths  to 
the  vulva  and  lower  part  of  the  abdomen,  to  administer  cold  and 
acidulated  drinks  in  abundance,  and  to  prescribe  acetate  of  lead  and 
opium,  or  gallic  acid,  on  account  of  their  supposed  haemostatic  effect. 
Of  late  years  the  judiciousness  of  these  recommendations  has  been 
strongly  contested.  Not  long  ago  an  interesting  discussion  took 
place  at  the  Obstetrical  Society  of  London,^  on  a  paper  in  which  Dr. 
Greenhalgh  advised  the  immediate  induction  of  labor  in  all  cases  of 
placenta  prosvia.^  No  less  than  six  metropolitan  teachers  of  mid- 
wifery took  part  in  it,  and,  although  they  differed  in  details,  they 
all  agreed  as  to  the  inadvisability  of  allowing  pregnancy  to  progress 
when  the  existence  of  placenta  prtevia  had  been  distinctly  ascer- 
tained. The  reasons  for  this  course  are  obvious  and  unanswerable. 
The  labor,  indeed,  very  often  comes  on  of  its  own  accord ;  but  should 
it  not  do  so,  the  patient's  life  must  be  considered  to  be  always  in 

»  Obst.  Trans.,  vol.  vi.  p.  188. 

[2  That  cases  of  premature  delivery  liave  no  special  element  of  clanger,  will  also 
appear  from  Dr.  King's  record  ;  as  tliere  were  23  recoveries  in  29  cases.  Eleven  chil- 
dren, two  at  6^  months,  were  also  saved. — Ed.] 


HEMORRHAGE    BEFORE    DELIVERY.  401 

jeopardy  until  the  case  is  terminated,  for  no  one  can  be  sure  that 
most  dangcroas,  or  even  fatal  flooding  may  not  at  any  moment  come 
on ;  and  the  nearer  to  term  the  patient  is,  the  greater  the  risk  to 
which  she  is  subjected.  Nor  is  the  safety  of  the  child  likely  to  be 
increased  by  delay.  Provided  it  has  arrived  at  a  viable  age,  the 
chances  of  its  being  born  alive  may  be  said  to  be  greater  if  preg- 
nancy be  terminated  at  once,  than  if  repeated  floodings  occur.  I 
think,  therefore,  that  it  may  be  safely  laid  down  as  an  axiom,  that 
no  attempt  should  be  made  to  prevent  the  termination  of  pregnancy, 
but  that  our  treatment  should  rather  contemplate  its  conclusion  as 
soon  as  possible.  An  exception  may,  however,  be  made  to  this  rule 
when  the  hemorrhage  occurs  for  the  first  time  before  the  seventh 
month  of  utero-gestation.  The  chances  of  the  child  surviving  would 
then  be  very  small,  and  if  the  hemorrhage  be  not  alarming,  as  at 
that  early  period  is  likely  to  be  the  case,  the  measures  indicated 
above  may  be  employed,  in  the  ]iope  of  carrjdng  on  the  pregnancy 
until  there  is  a  prospect  of  the  patient  being  delivered  of  a  living 
child.  But  little  benefit  is  likely  to  accrue  from  astringent  drugs. 
Perfect  rest  in  bed  is  more  likely  to  be  beneficial  than  anything  else ; 
and  astringent  vaginal  pessaries,  of  matieo  or  perchloride  of  iron, 
might  be  used  with  advantage  as  local  hemostatics. 

Various  Methods  of  Treaimeyit. — When  the  period  of  pregnancy,  or 
the  urgency  of  the  case,  determines  us  to  forego  any  attempt  at  tem- 
porizing, there  are  various  plans  of  treatment  to  be  considered. 
These  are  chiefly — -1.  Puncture  of  the  memhranes.  2.  Phig'jing  the 
vagina.  3.  Turning.  4.  Partial  or  com2:)lete  sejxiratioii  of  the  ijlacenta. 
It  will  be  well  to  consider  in  detail  the  relative  advantages  of,  and 
indications  for,  each  of  these.  It  is  seldom,  however,  that  we  can 
trust  to  any  one  per  se ;  in  most  cases  two  or  more  are  required  to 
be  used  in  combination. 

1.  Puncture  of  the  memhranes  is  recommended  by  Barnes  as  the 
first  measure  to  be  adopted  in  all  cases  of  placenta  previa,  suflS.cient 
to  cause  anxiety.  "  It  is,"  he  says,  "  the  most  generally  efhcacious 
remedy,  and  it  can  always  be  applied."  The  primary  object  gained 
is  the  increase  of  uterine  contraction,  by  the  evacuation  of  the  liquor 
amnii.  Although  the  first  effect  of  this  may  be  to  increase  the  flow 
of  blood  by  further  separation  of  the  placenta,  the  flooding  can 
generally  be  commanded  by  plugging,  until  the  os  is  sufficiently 
dilated  to  permit  the  passage  of  the  child.  As  a  rule,  there  is  no 
great  difficulty  in  effecting  the  jDuncture,  especially  if  the  placental 
presentation  be  only  partial.  A  quill,  or  other  suitable  contrivance, 
guided  by  the  examining  finger,  is  passed  through  the  cervix,  and 
pushed  through  the  membranes.  In  complete  placenta  previa  it  may 
not  be  so  easy  to  effect  the  evacuation  of  the  liquor  amnii ;  and,  al- 
though many  authorities  advise  the  penetration  of  the  substance  of 
the  placenta  itself,  I  am  inclined  to  think  that  it  would  be  better  to 
abandon  the  attempt,  in  such  cases,  and  trust  to  other  methods  of 
treatment. 

The  objections  which  have  been  raised  to  puncture  of  the  mem- 
branes are  chiefly,  that  it  interferes  with  the  gradual  dilatation  of 


402  LABOR. 

tlie  OS,  and  renders  the  operation  of  turning  mucli  more  difficult. 
The  OS  IS  not,  however,  so  rogukirlj  dilated  by  the  bag  of  membranes 
in  cases  of  placenta  prtevia,  as  it  is  in  ordinary  labors.  Moreover, 
the  cervical  tissues  are  generally  relaxed  by  the  hemorrhage,  and 
dilatation  is  easily  effected.  Should  we  desire  to  dilate  the  os,  pre- 
paratory to  turning,  we  can  readily  do  so  by  means  of  Barnes's  bags, 
which  act,  at  the  same  time,  as  an  efficient  plug.  The  objections, 
therefore,  are  not  so  weighty  as  they  might  have  been  before  these 
artificial  dilators  were  used.  I  am  inclined,  for  these  reasons,  to 
agree  with  the  recommendation  that  puncture  of  the  membranes 
should  be  resorted  to  in  all  cases  of  placenta  previa. 

2.  Plugging  of  the  vagina^  or,  still  better,  of  the  cavity  of  the  cer- 
vix itself,  is  especially  serviceable  in  cases  in  which  the  os  is  not  suffi- 
ciently dilated  to  admit  of  turning,  or  of  separation  of  the  placenta, 
and  in  which  the  hemorrhage  still  continues  after  the  evacuation  of 
the  liquor  amnii.  By  means  of  this  contrivance  the  escape  of  blood 
is  effisctually  controlled. 

The  best  way  of  plugging  is  to  introduce  a  sponge  tent  of  sufficient 
size  into  the  cervical  canal,  and  to  keep  it  m  situ  by  a  vaginal  plug ; 
the  best  material  for  the  latter,  and  the  method  of  introduction,  are 
described  under  the  head  of  abortion.  The  sponge  tent  not  only 
controls  the  hemorrhage  more  efiectually  than  any  other  means,  but 
is,  at  the  same  time,  effecting  dilatation  of  the  cervix.  It  cannot 
be  left  in  many  hours  on  account  of  the  irritation  produced,  and  of 
the  fetor  from  accumulating  vaginal  discharges.  As  long  as  it  is  in 
position,  we  should  carefully  examine,  from  time  to  time,  to  see  that 
no  blood  is  oozing  past  it.  If  preferred,  a  Barnes's  bag  may  be  used 
for  the  same  purpose. 

While  the  plug  is  in  situ^  other  modes  of  exciting  uterine  action 
may  be  very  advantageously  employed,  such  as  a  firm,  abdominal 
bandage,  occasional  friction  over  the  uterus,  and  repeated  doses  of 
ergot.  The  last  is  specially  recommended  by  Dr.  Greenhalgh,  who 
used,  at  the  same  time,  a  plug  formed  of  an  oblong  India-rubber  ball 
inflated  with  air,  and  covered  with  spongio-piline. 

Oil  the  removal  of  the  plug  we  may  find  that  considerable  dila- 
tation has  taken  place,  perhaps  to  a  sufficient  extent  to  admit  of 
labor  being  safely  ccmckided  by  the  natural  efforts.  In  that  case  we 
shall  find  that,  although  the  pains  continae,  no  fresh  hem.orrhage 
occurs.  Should  it  do  so,  it  will  be  necessary  to  adopt  further  meas- 
ures. [In  King's  table,  before  quoted,  there  are  15  cases  "  in  which 
the  tampon  appears  to  have  been  the  principal  reliance,"  and  of  these 
13  recovered  and  2  died,  with  a  saving  also  of  9  children.  Some  of 
our  obstetricians  are  inclined  to  condemn  the  tampon  as  ineffective, 
and  to  substitute  the  hot-water  douche ;  can  it  do  much  better  than 
this  ?— Ed.] 

3.  Turning  has  long  been  considered  the  remedy  par  excellence  in 
placenta  prajvia ;  and  it  is  of  unquestionable  value  in  suitable  cases. 
Much  harm,  however,  has  been  done  when  it  has  been  practised  be- 
fore the  OS  was  sufficiently  dilated  to  admit  of  the  passage  of  the 
hand,  or  when  the  patient  was  so  exhausted  by  previous  hemorrhage 


HEMORRHAGE    BEFORE    DELIVERY.  403 

as  to  be  unable  to  bear  the  shock  of  the  operation.  The  records  of 
many  fatal  cases  in  the  practice  of  those  who  taugiit,  as  did  the  large 
majority  of  the  older  writers,  that  turning  at  all  risks  was  essential, 
conclusively  prove  this  assertion. 

It  is  most  likely  to  prove  serviceable  when,  either  at  first,  or  after 
the  use  of  the  tampon,  the  os  is  sufficiently  dilated  to  admit  the  hand, 
and  when  the  strength  of  the  patient  is  not  much  enfeebled.  If  she 
have  a  small,  feeble,  and  thready  pulse,  it  is  certainly  inapplicable, 
unless  all  other  methods  of  arresting  the  hemorrhage  have  failed. 
And,  even  then,  it  would  be  well  to  atten\pt  to  rally  the  patient  from 
her  exhausted  state  by  stimulants,  etc.,  before  the  operation  is  com- 
menced. 

Provided  the  placental  presentation  be  partial,  the  operation  can 
be  performed  without  difiicalty  in  the  usual  way.  In  central  implan- 
tation the  passage  of  the  hand  may  give  rise  to  some  difficulty.  Dr. 
Eigby  recommends  that  it  should  be  pushed  through  the  substance 
of  the  placenta,  until  it  reaches  the  uterine  cavit}'.  It  is  hardly 
possible  to  conceive  how  this  could  be  done  without  completely 
detaching  the  placenta,  and  still  less  to  understand  how  the  foetus 
could  be  dragged  through  the  aperture  thus  made.  It  will  be  far 
better  to  pass  the  hand  by  the  border  of  the  placenta,  separating  it 
as  we  do  so;  and,  if  we  can  ascertain  to  which  side  of  the  cervix  it 
is  least  attached,  that  should  be  chosen  for  the  purpose.  In  all  cases 
in  which  it  is  possible,  turning  by  the  bi-polar  method  should  be 
preferred.  In  cases  of  placenta  prsevia  especially  it  offers  many  ad- 
vantages. The  operation  can  be  soon  performed;  complete  dilatation 
of  the  OS  is  not  so  necessary;  and  it  involves  less  bruising  of  the 
cervix,  which  is  likely  to  be  specially  dangerous.  When  once  a  foot 
has  been  brought  within  the  os,  the  delivery  need  not  be  hurried. 
The  foot  forms  a  plug,  which  effectually  prevents  all  further  loss; 
and  we  may  then  safely  wait  until  we  can  excite  uterine  contraction, 
and  terminate  the  labor  with  safety.  Fortunately,  the  relaxation  of 
the  uterus,  which  is  so  often  present,  facilitates  this  manner  of  per- 
forming version,  and  it  can  generally  be  successfully  accomplished. 
Should  the  case  be  one  which  is  otherwise  suitable  for  turning,  and 
the  requisite  amount  of  dilatation  of  the  cervix  not  be  present,  the 
latter  can  generally  be  effected  in  the  space  of  an  hour  or  more 
(while  at  the  same  time  a  further  loss  of  blood  is  effectually  pre- 
vented) by  the  use  of  Barnes's  bags. 

4.  Separation  of  the  Placenta. — Entire  separation  of  the  placenta 
was  originally  recommended  by  Simpson  in  his  well-known  paper  on 
the  subject.  The  reasons  which  induced  him  to  recommend  it  have 
already  been  stated.  It  is  a  mistake  to  suppose,  however,  as  is  so 
often  done,  that  he  intended  to  recommend  it  in  all  cases  alike.  This 
supposition  he  always  was  careful  to  deny.   He  advised  it  especially : — • 

1.  When  the  child  is  dead. 

2.  When  the  child  is  not  yet  viable. 

3.  When  the  hemorrhage  is  great  and  the  os  uteri  is  not  yet  suffi- 
ciently dilated  for  safe  turning.  This  was  the  state  in  11  out  of  39 
cases  (Lee). 


404:  LABOR. 

4.  AYlien  the  pelvic  passages  are  too  small  for  safe  and  easy 
turning. 

5.  When  the  mother  is  too  exhausted  to  bear  turning. 

6.  When  the  evacuation  of  the  liquor  amnii  fails. 

7.  When  the  uterus  is  too  firmly  contracted  for  turning.^ 

These  are  very  much  the  cases  in  which  all  modern  accoucheurs 
would  exclude  the  operation  of  turning ;  and  it  was  especially  when 
that  was  unsuitable  that  Simpson  advised  extraction  of  the  placenta. 
As  his  theory  of  the  source  of  hemorrhage  is  now  almost  universally 
disbelieved,  so  has  the  practice  based  on  it  fallen  into  disuse,  and  it 
need  not  be  discussed  at  length.  It  is  very  doubtful  whether  the 
complete  separation  and  extraction  of  the  placenta  was  a  feasible 
operation ;  unquestionably  it  can  be  by  no  means  so  easy  as  Simp- 
son's writings  would  lead  us  to  suppose.  The  introduction  of  the 
hand  far  enough  to  remove  the  placenta  in  an  exhausted  patient 
would  probably  cause  as  much  shock  as  the  operation  of  turning 
itself;  and  another  very  formidable  objection  to  the  procedure  is 
the  almost  certain  death  of  the  child,  if  any  time  elapse  between  the 
separation  of  the  placenta  and  the  completion  of  delivery.  The 
modification  of  this  method,  so  strongly  advocated  by  Barnes,  is 
certainly  much  easier  of  application,  and  would  appear  to  answer 
every  purpose  that  Simpson's  operation  effected.  It  is  impossible  to 
describe  it  better  than  in  Barnes's  own  words: — ^ 

^'■The  operation  is  this:  Pass  one  or  two  fingers  as  far  as  they  will 
go  through  the  os  uteri,  the  hand  being  passed  into  the  vagina  if 
necessary;  feeling  the  placenta,  insinuate  the  finger  between  it  and 
the  uterine  wall;  sweep  the  finger  round  in  a  circle  so  as  to  separate 
the  placenta  as  far  as  the  finger  can  reach ;  if  you  feel  the  edge  of 
the  placenta,  where  the  membranes  begin,  tear  open  the  membranes 
carefully,  especially  if  these  have  not  been  previously  ruptured ; 
ascertain,  if  you  can,  what  is  the  presentation  of  the  child  before 
withdrawing  your  hand.  Commonly,  some  amount  of  retraction  of 
the  cervix  takes  place  after  the  operation, 'and  often  the  hemorrhage 
ceases  J'' 

It  will  be  seen  from  what  has  been  said  that  no  one  rule  of  prac- 
tice can  be  definitely  laid  down  for  all  cases  of  placenta  prasvia.  Our 
treatment  in  each  individual  case  must  be  guided  b}^  the  particular 
conditions  that  are  present ;  and,  if  only  we  bear  in  mind  the  natural 
history  of  the  hemorrhage,  we  may  confidently  look  to  a  favorable 
termination. 

It  ma}^  be  useful,  in  conclusion,  to  recapitulate  the  rules  which 
have  been  laid  down  for  treatment  in  the  form  of  a  series  of  pro- 
positions:— 

I.  Before  the  child  has  reached  a  viable  age,  temporize,  provided 
the  hemorrhage  be  not  excessive,  until  pregnancy  has  advanced  suffi- 
ciently to  afford  a  reasonable  hope  of  saving  the  child.  For  this 
purpose  the  chief  indication  is  absolute  rest  in  bed,  to  which  other 

J  Selected  Obst.  Works,  p.  68.  ^  Obstet.  Operations,  2d  ed.,  p.  417. 


HEMORRHAGE    BEFORE    DELIVERY.  405 

accessory  means  of  preventing  hemorrhage,  such  as  cold,  astringent 
pessaries,  etc.,  may  be  added, 

II.  In  hemorrhage  occurring  after  the  seventh  month  of  utero- 
gestation,  no  attempt  should  be  made  to  prolong  the  pregnancy. 

III.  In  all  cases  in  which  it  can  be  easily  effected,  the  membranes 
should  be  ruptured.  By  this  means  uterine  contractions  are  favored 
and  the  bleeding  vessels  compressed. 

IV.  If  the  hemorrhage  be  stopped,  the  case  may  be  left  to  nature. 
If  flooding  continue,  and  the  os  be  not  sufficiently  dilated  to  admit 
of  the  labor  being  readily  terminated  by  turning,  tlie  os  and  the 
vagina  should  be  carefully  plugged,  while  uterine  contractions  are 
promoted  by  abdominal  bandages,  uterine  compression,  and  ergot. 
The  plug  must  not  be  left  in  beyond  a  few  hours. 

V.  If,  on  removal  of  the  plug,  the  os  be  sufficiently  expanded,  and 
the  general  condition  of  the  patient  be  good,  the  labor  may  be  ter- 
minated by  turning,  the  bi -polar  method  being  used  if  possible.  If 
the  OS  be  not  open  enough,  it  may  be  advantageously  dilated  by  a 
Barnes's  bag,  which  also  acts  as  a  plug. 

YI,  Instead  of,  or  before  resorting  to,  turning,  the  placenta  may 
be  separated  around  the  site  of  its  attachment  to  the  cervix.  Tliis 
practice  is  specially  to  be  preferred  when  the  patient  is  much  ex- 
hausted, and  in  a  condition  unfavorable  for  bearing  the  shock  of 
turnino;. 


CHAPTEE    XIY. 

HEMOEEHAG-E    FEOM    SEPAEATIOInT    OF    A    NOEMALLT    SITUATED 

PLACENTA, 

This  is  the  form  of  hemorrhage  which  is  generally  described  in. 
obstetric  works  as  '■'■  acciderdal^''  in  contra-distinction  to  the  "  unavoid- 
ahW''  hemorrhage  of  placenta  previa.  In  discussing  the  latter,  we 
have  seen  that  the  term  "accidental"  is  one  that  is  apt  to  mislead, 
and  that  the  causation  of  the  hemorrhage  in  placenta  prsevia  is,  in 
some  cases  at  least,  closely  allied  to  that  of  the  variety  of  hemorrhage 
we  are  now  considering. 

When,  from  any  cause,  separation  of  a  normally  situated  placenta 
occurs  before  delivery,  more  or  less  blood  is  necessarily  effused  from 
the  ruptured  utero-placental  vessels,  and  the  subsequent  course  of 
the  case  may  be  twofold.  1.  The  blood,  or  at  least  some  part  of  it, 
may  find  its  way  between  the  membranes  and  the  decidua,  and 
escape  from  the  os  uteri.  This  constitutes  the  typical  "  accidental" 
hemorrhage  of  authors.  2.  The  blood  may  fail  to  find  a  passage 
externally,  and  may  collect  .internally,  giving  rise  to  very  serious 
symptoms,  and  even  proving  fatal,  before  the  true  nature  of  the  case 


406  LABOR. 

is  recognized.  Cases  of  this  kind  are  by  no  means  so  rare  as  the 
small  amount  of  attention  paid  to  them  by  authors  might  lead  us  to 
suppose ;  and,  from  the  obscurity  of  the  symptoms  and  difficulty  of 
diagnosis,  they  merit  special  study.  Dr.  GoodelP  has  collected 
together  no  less  than  106  instances  in  which  this  complication 
occurred. 

Causes  and  Pathology. — The  causes  of  placental  separation  may  be 
very  various.  In  a  large  number  of  cases  it  has  followed  an  accident 
or  exertion  (such  as  slipping  down  f^tairs,  stretching,  lifting  heavy 
Aveights,  and  the  like),  which  has  probably  had  the  effect  of  lacerating 
some  of  the  placental  attachments.  At  other  times  it  has  occurred 
without  such  appreciable  cause,  and  then  it  has  been  referred  to  some 
change  in  the  uterus,  such  as  a  more  than  usually  strong  contraction 
producing  separation,  or  some  accidental  determination  of  blood 
causing  a  slight  extravasation  between  the  placenta  and  the  uterine 
wall,  the  irritation  of  which  leads  to  contraction  and  further  detach- 
ment. Causes  such  as  these,  which  are  of  frequent  occurrence,  will 
not  produce  detachment  except  in  women  otherwise  predisposed  to 
it.  It  generally  is  met  with  in  women  who  have  borne  many  child- 
ren, more  especially  in  those  of  weakly  constitution  and  impaired 
health,  and  rarely  in  primiparse.  Certain  constitutional  states  proba- 
bly predispose  to  it,  such  as  albuminuria,  or  exaggerated  anaemia ; 
and,  still  more  so,  degenerations  and  diseases  of  the  placenta  itself. 

This  form  of  hemorrhage  rarely  occurs  to  an  alarming  extent  until 
the  latter  months  of  pregnancy,  often  not  until  labor  has  commenced. 
The  great  size  of  the  placental  vessels  in  advanced  pregnancy  affords 
a  reasonable  explanation  of  this  fact. 

Symptoms  and  Diagnosis. — If,  after  separation  of  a  portion  of  the 
placenta,  the  blood  finds  its  way  between  the  membranes  and  the 
decidua,  its  escape  per  vaginam,  even  although  in  small  amount,  at 
once  attracts  attention,  and  reveals  the  nature  of  the  accident.  It 
is  otherwise  when  we  have  to  do  with  a  case  of  concealed  hemorrhage, 
the  diagnosis  of  which  is  often  a  matter  of  difficulty.  Then  the  blood 
probably  at  first  collects  between  the  uterus  and  the  placenta.  Some- 
times marginal  separation  does  not  occur,  and  large  blood-clots  are 
formed  in  this  situation,  and  retained  there.  More  often,  the  margin 
of  the  placenta  separates,  and  the  blood  collects  between  the  mem- 
branes and  the  uterine  wall,  either  towards  the  cervix,  where  the 
presenting  part  of  the  child  may  prevent  its  escape,  or  near  the 
fundus.  In  the  latter  case  especially,  the  coagula  are  apt  to  cause 
very  painful  stretching  and  distension  of  the  uterus.  The  blood 
may  also  find  its  way  into  the  amniotic  cavity,  but  more  frequently 
it  does  not  do  so;  probably,  as  Goodell  has  pointed  out,  because 
"should  the  os  uteri  be  closed,  the  membranes,  however  delicate, 
cannot,  other  things  being  equal,  rupture  any  sooner  from  the 
uterine  walls,  for  the  sum  of  the  resistance  of  the  inclosed  liquor 
amnii  being  equally  distributed  exactly  counterbalances  the  sum  of 
tha  pressure  exerted  by  the  effusion."    This  point  is  of  some  practical 

'•  Amer.  .lourn.  of  Obstet.,  vol.  ii. 


HEMORRHAGE    BEFORE    DELIVERY.  407 

importance  because,  after  rupture  of  the  membranes,  the  liquor  amnii 
is  frequently  found  untinged  with  blood,  and  this  might  lead  us  to 
suppose  ourselves  mistaken  in  our  diagnosis,  if  this  fact  were  not 
borne  in  mind. 

Symptoms  of  Concealed  Accidental  Hemorrliage. — The  most  promi- 
nent symptoms  in  concealed  internal  hemorrhage  are  extreme  col- 
lapse and  exhaustion,  for  which  no  adequate  cause  can  be  assigned. 
These  differ  from  those  of  ordinary  syncope,  with  which  they  might 
be  confounded,  chiefly  in  their  persistence  and  severity,  and  in  the 
presence  of  the  symptoms  attending  severe  loss  of  blood,  such  as 
coldness  and  pallor  of  the  surface,  great  restlessness  and  anxiety, 
rapid  and  sighing  respiration,  yawning,  feeble,  quick,  and  compres- 
sible pulse.  When  there  is  severe  internal,  with  slight  external 
hemorrhage,  we  may  be  led  to  a  proper  diagnosis  by  observing  that 
the  constitutional  symptoms  are  much  more  severe  than  the  amount 
of  external  hemorrhage  would  account  for.  Uterine  pain  is  gene- 
rally present,  of  a  tearing  and  stretching  character,  sometimes  mode- 
rate in  amount,  more  often  severe,  and  occasionally  amounting  to 
intolerable  anguish.  It  is  often  localized,  and  it,  doubtless,  depends 
on  the  distension  of  the  uterus  by  the  retained  coagula.  If  the  dis- 
tension be  marked,  there  may  be  an  irregularity  in  the  form  of  the 
uterus  at  the  site  of  sanguineous  effusion ;  but  this  will  be  difficult 
to  make  out,  except  in  women  with  thin  and  unusually  lax  abdomi- 
nal parietes.  A  rapid  increase  in  the  size  of  the  uterus  has  been 
described  as  a  sign  by  Cazeaux  and  others.  It  is  not  very  likely 
that  this  will  be  appreciable  towards  the  end  of  ntero  gestation,  as  a 
very  large  amount  of  effusion  would  be  necessary  to  produce  it.  At 
an  earlier  period  of  pregnancy,  at  or  about  the  fifth  month,  I  made  it 
out  very  distinctly  in  a  case  in  my  own  practice.  It  obviously  must 
have  occurred  to  an  enormous  extent  in  a  case  related  by  Chevalier, 
in  which  post-mortem  Cfesarean  section  was  performed  under  the  im- 
pression that  the  pregnancy  had  advanced  to  term,  but  only  a  three 
months'  foetus  was  found,  imbedded  in  coagula  which  distended  the 
uterus  to  the  size  of  a  nine  months'  gestation.^  Labor  pains  may  be 
entirely  absent.  If  present^  they  are  generally  feeble,  irregular,  and 
inefficient. 

Differential  Diagiiosis. — The  only  condition,  besides  ordinary  syn- 
cope, likely  to  be  confounded  with  this  form  of  hemorrhage,  is  rup- 
ture of  the  uterus,  to  which  the  intense  pain  and  profound  collapse 
induce  considerable  resemblance.  The  latter  rarely  occurs  until  after 
labor  has  been  sometime  in  progress,  and  after  the  escape  of  the 
liquor  amnii ;  whereas  hemorrhage  usually  occurs  either  before  labor 
has  commenced,  or  at  an  early  stage.  The  recession  of  the  presenta- 
tion, and  the  escape  of  the  foetus  into  the  abdominal  cavity,  in  cases 
of  rupture,  will  further  aid  in  establishing  the  diagnosis. 

Prognosis. — The  prognosis,  when  blood  escapes  externally,  is,  on 
the  whole,  not  unfavorable.  The  nature  of  the  case  is  apparent,  and 
remedial  measures  are  generally  adopted  sufficiently  early  to  prevent 

■  Journ.  de  Med.  Clin,  et  Pharmac,  vol.  xsi.  p.  363. 


408  LABOR. 

serious  mischief.  It  is  different  witli  tlie  concealed  form,  in  wliicTi 
the  mortality  is  very  great.  Out  of  Goodell's  106  cases,  no  less  than 
54  mothers  died.  This  excessive  death-rate  is,  no  doubt,  partly  due 
to  the  fact  that  extreme  prostration  so  often  occurs  before  the  exist- 
ence of  hemorrhage  is  suspected,  and  partly  to  the  accident  generally 
happening  in  women  of  weakly  and  diseased  constitution.  The  prog- 
nosis to  the  child  is  still  more  grave.  Out  of  107  children,  only  6 
were  born  alive.  The  almost  certain  death  of  the  child  may  be  ex- 
plained by  the  fact  that,  when  blood  collects  between  the  iiterus  and 
the  placenta,  the  foetal  portion  of  the  latter  is  probably  lacerated, 
and  the  child  then  also  dies  from  hemorrhage. 

Treatment. — In  this,  as  in  all  other  forms  of  puerperal  hemorrhage, 
the  great  hemostatic  is  uterine  contraction,  and  that  we  must  try  to 
encourage  by  all  possible  means.  The  first  thing  to  be  done,  whether 
the  hemorrhage  be  apparent  or  concealed,  is  to  rupture  the  mem- 
branes. If  the  loss  of  blood  be  only  slight,  this  may  suffice  to  con- 
trol it,  and  the  case  may  then  be  left  to  nature.  A  firm  abdominal 
binder,  should,  however,  be  applied  to  prevent  any  risk  of  blood  col- 
lecting internally,  as  there  is  nothing  to  prevent  its  filling  the  uterine 
cavity  after  the  membranes  are  ruptured.  Contraction  may  be 
further  advantageously  solicited  by  uterine  compression,  and  by  th^ 
administration  of  full  doses  of  ergot.  If  hemorrhage  continue,  or  if 
we  have  any  reason  to  suspect  concealed  hemorrhage,  the  sooner  the 
uterus  is  emptied  the  better.  If  the  os  be  sufficiently  dilated,  the 
best  practice  will  be  to  turn  without  further  delay,  using  the  bi-polar 
method  if  possible.  If  the  os  be  not  open  enough,  a  Barnes's  bag 
should  be  introduced,  while  firm  pressure  is  kept  up  to  prevent 
uterine  accumulation.  Should  the  collapsed  condition  of  the  patient 
be  very  marked,  the  mere  shock  of  the  0[)eration  might  turn  the 
scale  against  her.  Under  such  circumstances  it  may  be  better  prac- 
tice to  delay  further  procedure  until,  by  the  administration  of  stimu- 
lants, warmth,  etc.,  we  have  succeeded  in  producing  some  amount  of 
reaction,  keeping  up,  in  the  meanwhile,  firm  pressure  on  the  uterus. 
Should  the  head  be  low  down  in  the  pelvis,  it  may  be  easier  to  com- 
plete labor  by  means  of  the  forceps. 


CHAPTEE   XY. 

HEMOERHAGE   AFTER    DELIVERY. 

Hemorrhage  during,  or  shortly  after,  the  third  stage  of  labor  is 
one  of  the  most  trying  and  dangerous  accidents  connected  with  partu- 
rition. Its  sudden  and  unexpected  occurrence  just  after  the  labor 
appears  to  be  happily  terminated,  and   its  alarming  effect  on  the 


HEMORRHAGE    AFTER    DELIVERY.  409 

patient,  who  is  often  placed  in  the  utmost  danger  in  a  few  moments, 
tax  the  presence  of  mind  and  the  resources  of  the  practitioner  to  the 
utmost,  and  render  it  an  imperative  duty  on  every  one  who  practises 
midwifery  to  malce  himself  thoroughly  acquainted  with  its  causes, 
and  preventive  and  curative  treatment.  There  is  no  emergency  in 
obstetrics  which  leaves  less  time  for  reflection  and  consultation,  and 
the  life  of  the  patient  Avill  often  depend  on  the  prompt  and  imme- 
diate action  of  the  medical  attendant. 

Frequency  of  Post-partum  Hemorrhage. — Post-partum  hemorrhage 
is  one  of  the  most  frequent  complications  of  delivery,  I  do  not 
know  of  any  statistics  which  enable  us  to  judge  with  accuracy  of  its 
frequency,  but  I  believe  it  to  be  an  unquestionable  fact  that,  espe- 
cially in  the  upper  ranks  of  society,  it  is  very  common  indeed.  Tliis 
is  probably  due  to  the  effects  of  civilization,  and  to  the  mode  of  life 
of  patients  of  that  class,  whose  whole  surroundings  tend  to  produce 
a  lax  habit  of  body  which  favors  uterine  inertia,  the  principal  cause 
of  post-partum  hemorrhage.  In  the  report  of  the  Eegistrar-General 
for  the  five  years,  from  1872  to  1876,  8524  deaths  are  attributed  to 
flooding.  The  majority  of  these  must  have  been  caused  by  post- 
partum hemorrhage,  although  some  may  have  been  from  other  forms. 
*  Generally  a  Preventable  Accident. — Fortunately,  it  is,  to  a  great 
exteiit,  a  preventable  accident.  I  believe  this  fact  cannot  be  too 
strongly  impressed  on  the  practitioner.  If  the  third  stage  of  labor 
be  properly  conducted,  if  every  case  be  treated,  as  every  case  ought 
to  be,  as  if  hemorrhage  were  impending,  it  would  be  much  more  in- 
frequent than  it  is.  It  is  a  curious  fact  that  post-partum  hemorrhage 
is  much  more  common  in  the  practice  of  some  medical  men  than  in 
that  of  others ;  the  reason  being,  that  those  who  meet  with  it  often 
are  careless  in  their  management  of  tlieir  patients  immediately  after 
the  birth  of  the  child.  That  is  just  the  time  when  tbe  assistance  of 
a  properly  qualified  practitioner  is  of  value,  much  more  so  than 
before  the  second  stage  of  labor  is  concluded  ;  hence  when  I  hear 
that  a  medical  man  is  constantly  meeting  with  severe  post-partum 
hemorrhage,  I  hold  myself  justified  ipso  facto  in  inferring  that  he 
does  not  know,  or  does  not  practise,  the  proj)er  mode  of  managing 
the  third  stage,  of  labor. 

Causes  and  JSfature^s  Method  of  Controlling  Hemorrhage  after  De- 
livery.— The  placenta,  as  we  have  seen,  is  separated  by  the  last  pains, 
and  the  blood,  which  in  greater  or  less  quantity  accompanies  the 
foetus,  probably  comes  from  the  utero-placental  vessels  which  are 
then  lacerated.  Almost  immediately  afterwards  the  uterus  contracts 
firmly,  and,  in  a  typical  labor,  assumes  the  hard  cricket-ball  form 
which  is  so  comforting  to  the  accoucheur  to  feel.  The  result  is  the 
compression  of  all  the  vascular  trunks  which  ramify  in  its  walls,  both 
arteries  and  veins,  and  thus  the  flow  of  blood  through  them  is  pre- 
vented. By  referring  to  what  has  been  said  as  to  the  anatomy  of  the 
muscular  fibres  of  the  gravid  uterus,  especially  at  the  placental  site 
(p.  52),  it  will  be  seen  how  admirably  they  are  adapted  for  this 
purpose.  The  arrangement  of  the  vessels  themselves  favors  the 
haemostatic  action  of  uterine  contraction.  The  large  venous  sinuses 
27 


410  LABOR. 

are  placed  in  layers,  one  above  the  other,  in  the  thickness  of  the 
uterine  walls,  and  they  anastomose  freely.  When  the  superimposed 
layers  communicate  with  those  immediately  below  them,  the  junc- 
tion is  by  a  falciform  or  semilunar  opening  in  the  floor  of  the  vessel 
nearest  the  external  surface  of  the  uterus.  Within  the  margins  of 
this  aperture  there  are  muscular  fibres,  the  contraction  of  which 
probably  tends  to  prevent  retrogression  of  blood  from  one  layer  of 
vessels  into  the  other.  The  venous  sinuses  themselves  are  of  a  flat- 
tened form,  and  they  are  intimately  attached  to  the  muscular  tissues. 
It  is  obvious,  then,  that  these  anatomical  arrangements  are  emi- 
nently adapted  to  facilitate  the  closure  of  the  vessels.  They  are, 
however,  large,  and  are  destitute  of  valves  ;  and,  if  contraction  be 
absent,  or  if  it  be  partial  and  irregular,  it  is  equally  easy  to  under- 
stand why  blood  should  pour  forth  in  the  appalling  amount  which  is 
sometimes  observed. 

Importance  of  Tonic  Uterine  Contraction. — If  uterine  action  be  firm, 
regular,  and  continuous,  the  vessels  must  be  sealed  up,  and  hemor- 
rhage effectually  prevented.  This  fact  has  been  doubted  by  many 
authorities.  Gooch  was  the  first  to  describe  what  he  called  "a  pecu- 
liar form  of  hemorrhage"  accompanying  a  contracted  womb,  and 
similar  observations  have  been  made  by  other  writers,  such  as 
Velpeau,  Rigby,  and  Gendrin.  Simpson  says,  on  this  point,  that 
strong  uterine  contractions  "  are  not  probably  so  essential  a  part  in 
the  mechanism  of  the  prevention  of  hemorrhage  from  the  open  ori- 
fices of  the  uterine  veins  as  we  might  a  'priori  suppose."'  With  re- 
gard to  Gooch's  cases,  it  has  been  pointed  out  that  his  own  description 
proves  that,  however  firmly  the  uterus  may  have  contracted  imme- 
diately after  the  expulsion  of  the  child,  it  must  have  subsequently 
relaxed,  for  he  passed  his  hand  into  it  to  remove  retained  clots,  a 
manoeuvre  which  he  could  not  have  practised  had  tonic  contraction 
been  present.  Barnes  suggests  that  in  some  of  these  cases  the 
hemorrhage  came  from  a  laceration  of  the  cervix.  Of  course,  blood 
may  readily  escape  from  mechanical  injury  of  this  kind,  although 
the  uterus  itself  be  in  a  satisfactory  state  of  contraction,  and  the 
possibility  of  this  occurrence  should  always  be  borne  in  mind. 

Although,  then,  we  may  admit  that   post-partum  hemorrhage  is 
incompatible  with  persistent  contraction  of  the  uterus,  it  by  no  means 
follows  that  the  converse  is  true.     On  the  contrary,  it  is  not  uncom- 
mon to  meet  with  cases  in  which  the  uterus  is  large  and  apparently 
quite  flaccid,  and  in  which  there  is  no  loss  of  blood.     Alternate  re- 
laxation and  contraction  of  the  uterus  after  delivery  are  also  of  con- 
■stant  occurrence,  and  yet  hemorrhage,  during  the  relaxation,  does 
'not  take  place.    The  explanation  no  doubt  is  that,  immediately  after 
the  birth  of  the  child,  there  was  sufficient  contraction  to  prevent 
hemorrhage,  and  that,  during  its  continuance,  coagula  formed  in  the 
mouths  of  the  uterine  sinuses,  by  which  they  were  sufficiently  oc- 
cluded to  prevent  any  loss  when  subsequent  relaxation  occurred. 
In  all  probability  both  uterine  contraction  and  thrombosis  are  in 

'  Selected  Obstetric  Works,  p.  234. 


HEMORRHAGE    AFTER    DELIVERY.  411 

operation  in  ordinary  cases ;  and  we  shall  presently  see  that  all  the 
means  employed  in  the  treatment  of  post-partum  hemorrhage  act  by 
producing  one  or  other  of  them. 

Secondary  Causes  of  IlemorrJuige. — Uterine  inertia  after  labor,  then, 
may  be  regarded  as  the  one  great  primary  cause  of  post-partum 
hemorrhao-e;  bat  there  are  various  secondary  causes  which  tend  to 
produce  it,  one  of  the  most  frequent  of  which  is  exhaustion  follow- 
ing a  protracted  labor.  The  uterus  gets  worn  out  by  its  eftbrts,  and 
when  the  foetus  is  expelled,  it  remains  in  a  relaxed  state,  and  hemor- 
rhage results.  Over-distension  of  the  uterus  acts  in  the  same  way. 
Hence  hemorrhage  is  very  frequently  met  with  when  there  has  been 
an  excessive  amount  of  liquor  amnii,  or  in  multiple  pregnancies. 
One  of  the  worst  cases  I  ever  met  with  was  after  the  birth  of  triplets, 
the  uterus  having  been  of  an  enormous  size.  Kapid  emptying  of  the 
uterus,  during  which  there  has  not  been  sufficient  time  for  complete 
separation  of  the  placenta,  often  tends  to  the  same  result.  This  is 
the  reason  why  hemorrhage  so  frequently  follows  forceps  delivery, 
especially  if  the  operation  have  been  unduly  hurried;  and  it  is  one 
of  the  chief  dangers  in  what  are  termed  "  precipitate  labors."  The 
general  condition  of  the  patient  may  also  strongly  predispose  to  it. 
Thus  it  is  more  often  met  with  in  women  who  have  borne  families, 
especially  if  they  be  weakly  in  constitution,  comparatively  seldom 
in  priniiparse;  and  for  the  same  reason  that  after-pains  are  most 
common  in  the  former,  namely,  that  the  uterus,  Aveakened  by  frequent 
child-bearing,  contracts  inefficiently.  The  experience  of  practitioners 
in  the  tropics  shows  that  European  women,  debilitated  by  the  relax- 
ing effects  of  warm  climates,  are  peculiarly  prone  to  it,  and  it  forms 
one  of  the  chief  dangers  of  childbirth  amongst  the  English  ladies  in 
India. 

Irregular  Uterine  Contraction. — Another  important  cause  of  post- 
partum hemorrhage  is  partial  and  irregular  contraction  of  the  uterus. 
Part  of  the  muscular  tissue  is  firmly  contracted,  while  another  part 
is  relaxed,  and  the  latter  very  often  the  placental  site.  This  has 
been  especially  dwelt  on  by  Simpson.  He  says  "the  morbid  con- 
dition which  is  most  frequently  and  earliest  seen  in  connection  with 
post-partum  hemorrhage,  is  a  state  of  irregularity  and  want  of  equa- 
bility in  the  contractile  action  of  different  parts  of  the  uterus — and, 
it  may  be  in  different  planes  of  the  muscular  fibres — as  marked  by 
one  or  more  points  in  the  organ  feeling  hard  and  contracted,  at  the 
same  time  that  other  portions  of  the  parietes  are  soft  and  relaxed." 

Hour-glass  Contraction. — One  peculiar  variety,  which  has  been 
much  dwelt  on  by  writers,  and  is  a  prominent  bugbear  to  obstetri- 
cians, is  the  so-cailed  "  liour-glass  contraction.''''  This  in  reality  seems 
to  depend  on  spasmodic  contraction  of  the  internal  os  uteri,  by  means 
of  which  the  placenta  becomes  encysted  in  the  upper  portion  of  the 
uterus,  which  is  relaxed.  On  introducing  the  hand,  it  first  passes 
through  the  lax  cervical  canal,  until  it  comes  to  the  closed  internal 
OS.  with  the  umbilical  cord  passing  through  it,  which  has  generally 
been  supposed  to  be  a  circular  contraction  of  a  portion  of  the  body 
of  the  uterus. 


412 


LABOR. 


Encystment  of  the  placenta,  however,  althougli  more  rarely,  un- 
questionably takes  place  in  a  portion  only  of  the  body  of  the  uterus 
(Fig.  139).^     Then  apparently  the  placental  site  remains  more  or 


Fig.  139. 


Irregular  Contraction  of  the  Uterus,  with  Encystment  of  the  Placenta. 

less  paralyzed,  with  the  placenta  still  attached,  while  the  remainder 
of  the  body  of  the  uterus  contracts  firmly,  and  thus  encystment  is 
produced. 

Causes  of  Irregular  Contractions. — These  irregular  contractions  of 
the  uterus  are  by  no  means  so  common  as  our  older  authors  supposed. 
When  they  do  occur  I  believe  them  almost  invariably  to  depend  on 
defective  management  of  the  third  stage  of  labor.  "  The  most  fre- 
quent cause,"  says  Bigby,^  "is  from  over-anxiety  to  remove  the 
placenta;  the  cord  is  frequently  pulled  at,  and  at  length  the  os  uteri 
is  excited  to  contract."  While  this  is  being  done,  no  attempts  are 
probably  being  made  to  excite  the  fundus  to  proper  action,  and, 
therefore,  the  hour-glass  contraction  is  established.  Duncan  says  of 
this  condition  :  "  Hour-glass  contraction  cannot  exist  unless  the  parts 

\}  The  right  hand  illustration  has  been  a  subject  of  contest  for  many  years,  and 
was  very  recently  condemned  in  a  discussion  at  a  meeting  of  the  Philadelphia  Obstet- 
rical Society.  It  is  claimed  by  but  few  obstetricians  that  there  ever  has  been  such 
a  contraction  as  this.  No  one  at  the  meeting  appeared  to  believe  that  the  uterus  was 
subject  to  a  true  central  constriction  ;  still,  one  claimed  that  the  contraction  was 
located  at  the  internal  os,  and  another  that  it  was  sometimes  high  in  the  organ. 
Prof.  Meigs  taught  that  an  irregularly  contracted  uterus  was  the  effect  of  an  adherent  pla- 
centa acting  as  an  obstacle  to  contraction  over  the  seat  of  union,  while  the  rest  of  the  organ 
was  free  to  contract.  Some  men  of  very  extensive  experience  still  hold  to  this  view. 
Others  having  equal  advantages  claim  that  the  body  of  the  organ  contracts  uniformly  ; 
that  the  internal  os  may  be  spasmodically  constricted  ;  and  the  cervix  at  the  same 
time  remain  dilated  as  a  flaccid  bag,  or  funnel-shaped  vestibule.  This  latter  view 
is  based  upon  the  belief  that  the  arrangement  of  the  circular  muscular  fibres  is  such 
that  a  violent  linear  contraction  in  the  body  of  the  uterus  must  be  an  anatomical 
impossibility.  The  recent  discussions  upon  "  tetanoid  constriction  of  the  uterus,"  as 
a  most  obstinate  form  of  dystocia,  have  revived  the  question  as  to  the  exact  seat  of 
spasm,  and  may  lead  eventually  to  an  exact  determination  of  the  zone  of  fibres  in- 
volved.— En.] 

2  Rigby's  Midwifery,  p.  225. 


HEMORRHAGE    AFTER    DELIVERY.  413 

above  the  contraction  are  in  a  state  of  inertia;  were  the  higher 
parts  of  the  uterus  even  in  moderate  action,  the  hour-glass  contrac- 
tion would  soon  be  overcome."'  If  placental  expression  were  always 
employed,  if  it  were  the  rule  to  effect  the  expulsion  of  the  placenta 
by  a  vis  d  tergo^  instead  of  extracting  by  a  vis  cL  fronte^  I  feel  con- 
fident that  these  irregular  and  spasmodic  contractions — of  the  influ- 
ence of  which  in  producing  hemorrhage  there  can  be  no  question — 
would  rarely,  if  ever,  be  met  with.  It  is  to  be  observed  that  even 
in  these  cases,  it  is  not  because  the  uterus  is  in  a  state  of  partial  con- 
traction, but  because  it  is  in  a  state  of  partial  relaxation,  that  hemor- 
rhage ensues. 

Placental  Adhesions. —  Adhesions  of  the  placenta  to  tlie  uterine 
parietes  may  cause  hemorrhage,  especially  if  they  be  partial,  and 
the  remainder  of  the  placentae  be  detached.  The  frequencv  of  these 
has  been  over-estimated.  Many  cases  believed  to  be  examples  of 
adherent  placenta  are,  in  reality,  only  cases  of  placentae  retained 
from  uterine  inertia.  The  experience  of  all  who  see  much,  midwifery 
will  probably  corroborate  tlie  observation  of  Braun,  that  "abnormal 
adhesion  and  hour-glass  contraction  are  more  frequently  encountered 
in  the  experience  of  the  young  practitioner,  and  they  diminish  in 
frequency  in  direct  ratio  to  increasing  years. '"^  The  cause  of  adhe- 
sion is  often  obscure,  but  it  most  probably  results  from  a  morbid 
state  of  the  decidua,  whicli  is  produced  by  antecedent  disease  of  the 
uterine  mucous  membrane:  then  the  adhesion  is  apt  to  recur  in  sub- 
sequent pregnancies.  The  decidua  is  altered  and  thickened,  and 
patches  of  calcareous  and  fibrous  degeneration  may  be  often  found 
on  the  attached  surface  of  the  placenta.  Most  frequently  the  placenta 
is  only  partially  adherent;  patches  of  it  remain  firmly  attached  to 
the  uterus,  while  the  rest  is  separated  :  hence  the  uterine  walls  re- 
main relaxed,  and  hemorrhage  frequently  follows.  The  diagnosis 
and  management  of  these  very  troublesome  cases  will  be  found  de- 
scribed under  the  head  of  treatment  (p.  417). 

Constitutional  Predisposition  to  .Flooding. — Finally  I  think  it  must 
be  admitted  that  there  are  some  women  who  really  merit  the  appel- 
lation of  "Flooders,"  which  has  been  applied  to  them,  and  who,  do 
what  we  may,  have  the  most  extraordinary  tendency  to  hemorrhage 
after  delivery.  I  do  not  think  that  these  cases,  however,  are  by  any 
means  so  common  as  some  have  supposed.^  I  have  attended  several 
patients  who  have  nearly  lost  their  lives  from  post-partum  hemor- 
rhage in  former  labors,  some  who  have  suffered  from  it  in  every  pre- 
ceding confinement,  and  I  have  only  met  with  two  cases  in  which 
the  assiduous  use  of  preventive  treatment  failed  to  avert  it.  In  these 
(one  of  which  I  have  elsewhere  published  in  detail^),  in  spite  of  all 
my  efforts,  I  could  not  succeed  in  keeping  up  uterine  contraction, 
and  the  patients  would  certainly  have  lost  their  lives  were  it  not  for 
the  means  which  modern  improvements  have  fortunately  placed  at 
our  disposal  for  producing  thrombosis  in  the  mouths  of  the  bleeding 

'  Researches  in  Obstetrics,  p.  389.  2  Braun's  Lectures,  1S69. 

[^  See  remarks  on  quinia,  p.  338. — Ed.]  *  Obst.  Journ.,  voL  i. 


414  LABOR. 

vessels.  The  nature  of  these  rare  cases  requires  further  investiga- 
tion :  possibly  they  may,  to  some  extent,  be  the  subjects  of  the  so- 
called  hemorrhagic  diathesis. 

jSirns  and  Symptoms. — The  loss  of  blood  may  commence  immedi- 
ately alter  the  birth  of  the  child,  before  the  expulsion  of  the  placenta, 
or  not  until  some  time  afterwards,  when  the  contracted  uterus  has 
again  relaxed.  It  may  commence  gradually,  or  suddenly  ;  in  the 
latter  case,  it  may  begin  with  a  gush,  and  in  the  worst  form  the  bed- 
clothes, the  bed,  and  even  the  floor,  are  deluged  with  the  blood  which, 
it  is  no  exaggeration  to  say,  is  pouring  from  the  patient.  If  now  the 
hand  be  placed  on  the  abdomen,  we  shall  miss  the  hard  round  ball 
of  the  contracted  uterus,  which  will  be  found  soft  and  flabby,  or  we 
may  even  be  unable  to  make  out  its  contour  at  all.  If  the  hemor- 
rhage be  slight,  or  if  we  succeed  in  controlling  it  at  once,  no  serious 
consequences  follow ;  but  if  it  be  excessive,  or  if  we  fail  to  check  it, 
the  gravest  results  ensue. 

Exhaustion  in  Extreme  Cases. — There  are  few  sights  more  appal- 
ling to  witness  than  one  of  the  worst  cases  of  postpartum  hemorrhage. 
The  pulse  becomes  rapidly  affected,  and  may  be  reduced  to  a  mere 
thread,  or  it  may  become  entirely  imperceptible.  Syncope  often 
comes  on,  not  in  itself  always  an  unfavorable  occurrence,  as  it  tends 
to  promote  thrombosis  in  the  venous  sinuses.  Or,  short  of  actual 
syncope,  there  may  be  a  feeling  of  intense  debility  and  faintness. 
Extreme  restlessness  soon  supervenes,  the  patient  throws  herself 
about  the  bed,  tossing  her  arms  wildly  above  her  head  ;  respiration 
becomes  gasping  and  sighing,  the  "besoin  de  respirer"  is  acutelj^felt, 
and  the  patient  cries  out  for  more  air  ;  the  skin  becomes  deadly  cold, 
and  covered  with  profuse  perspiration ;  if  the  hemorrhage  continue 
unchecked,  we  next  may  have  complete  loss  of  vision,  jactitation, 
convulsions,  and  death. 

Formidable  as  such  symptoms  are,  it  is  satisfactory  to  know  that 
recovery  often  takes  place,  even  when  the  powers  of  life  seem  reduced 
to  the  lowest  ebb.  If  we  can  check  the  hemorrhage  while  there  is 
still  some  power  of  reaction  left,  however  slight,  we  may  not  unrea- 
sonably hope  for  eventual  recovery.  The  constitution,  however,  may 
have  received  a  severe  shock,  and  it  may  be  montlis,  or  even  years, 
before  the  patient  recovers  from  the  effects  of  only  a  few  minutes' 
hemorrhage.  A  death-like  pallor  frequently  follows  these  excessive 
losses,  and  the  patient  often  remains  blanched  and  exsanguine  for  a 
long  time. 

Preventive  Treatment. — The  preventive  treatment  of  post-partum 
hemorrhage  should  be  carefully  practised  in  every  case  of  labor, 
however  normal.  If  the  practitioner  make  a  habit  ot  never  remov- 
ing his  hand  from  the  uterus  after  the  birth  of  the  child  until  the 
placenta  is  expelled,  and  of  keeping  up  continuous  uterme  contrac- 
tion for  at  least  half  an  hour  after  delivery  is  completed,  not  neces- 
sarily by  friction  on  tlie  fundus,  but  by  simply  grasping  the  contracted 
womb  with  the  palm  of  the  hand  and  preventing  its  undue  relaxation, 
cases  of  post-  partum  flooding  will  seldom  be  met  with.  As  a  rule 
we  should,  I  think,  not  apply  the  binder  until  at  least  that  time  has 


nEMORUHAGE    AFTER    DELIVERY.  415 

elapsed.  The  binder  is  an  efFectivc  means  of  keeping  up,  but  not  of 
producing,  contraction,  and  it  should  never  be  trusted  to  ibr  the  latter 
purpose.  If  it  be  put  on  too  soon,  the  uterus  niay  relax  under  it, 
and  become  filled  with  clots  without  the  practitioner  knowing  any- 
thing about  it ;  whereas  this  cannot  possibly  take  place  as  long  as 
the  uterine  globe  is  held  in  the  hollow  of  the  hand.  I  have  seen 
more  than  one  serious  case  of  concealed  hemorrhage  result  from  the 
too  common  habit  of  putting  on  the  binder  immediately  after  the 
removal  of  the  placenta.  I  believe  also,  as  I  have  formerly  said, 
that  it  is  thoroughly  good  practice  to  administer  a  full  dose  of  the 
liquid  extract  of  ergot  in  all  cases  after  the  placenta  has  been  ex- 
pelled, to  insure  persistent  contraction,  and  to  lessen  the  chance  of 
blood-clots  being  retained  in  utero. 

These  are  the  precautions  which  should  be  used  in  all  cases  alike ; 
but  when  we  have  reason  to  fear  the  occurrence  of  hemorrhage,  from 
the  history  of  previous  labors  or  other  cause,  special  care  should 
be  taken.  The  ergot  should  be  given,  and  preferably  in  the  form  of 
the  subcutaneous  injection  of  ergotine,  before  the  birth  of  the  child, 
wdien  the  presentation  is  so  far  advanced  that  we  estimate  that  labor 
will  be  concluded  in  from  ten  to  twenty  minutes,  as  we  can  hardly 
expect  the  drug  to  produce  any  effect  in  less  time.  Particular  atten- 
tion, moreover,  should  then  be  paid  to  the  state  of  the  uterus.  Every 
means  should  be  taken  to  insure  regular  and  strong  contraction,  and 
it  is  advisable  to  rupture  the  membranes  early,  as  soon  as  the  os  is 
dilated  or  dilatable,  to  insure  stronger  iiterine  action.  If  any  tend- 
ency to  relaxation  occur  after  delivery,  a  piece  of  ice  should  be 
passed  into  the  vagina,  or  into  the  uterus.  Should  coagula  collect 
in  the  uterus,  they  may  be  readily  expelled  by  firm  pressure  on  the 
fundus,  and  the  finger  should  be  passed  occasionally  up  to  the  cervix, 
and  any  which  are  felt  there  should  be  gently  picked  away. 

We  should  be  specially  on  our  guard  in  all  cases  in  whicb  the 
pulse  does  not  fall  after  delivery.  If  it  beat  at  100  or  more  some 
ten  minutes  or  a  quarter  of  an  hour  after  the  birth,  of  the  child, 
hemorrhage  not  unfrequently  follows;  anl,  hence,  it  is  a  good  prac- 
tical rule,  which  may  save  much  trouble,  that  a  patient  should  never 
be  left  unless  the  pulse  has  fallen  to  its  natural  standard. 

Curative  Treatment. — -As  there  are  only  two  means  vfhich  nature 
adopts  in  the  jDrevention  of  post-partum  hemorrhage,  so  the  remedial 
measures  also  may  be  divided  into  two  classes.  1.  Those  which  act 
by  the  production  of  uterine  contraction.  2.  Those  which  act  by 
producing  thrombosis  in  the  vessels.  Of  these  the  first  are  the  most 
commonly  used ;  and  it  is  only  in  the  worst  cases,  in  which  they  have 
been  assiduously  tried  and  have  failed,  that  we  resorted  to  those  com- 
ing under  the  second  heading. 

Uterine  Pressure. — The  patient  should  be  placed  on  her  back,  in 
which  position  we  can  more  readily  command  the  uterus,  as  well  as 
attend  to  her  general  state.  If  the  uterus  be  found  relaxed  and  full 
of  clots,  by  firmly  grasping  it  in  the  hand  contraction  may  be  evoked, 
its  contents  expelled,  and  further  hemorrhage  at  once  arrested. 
Should  this  fortunately  be  the  case,  we  must  keep  up  contraction  by 


416  LABOK. 

gentlj  kneading  the  titerus,  until  we  are  satisfied  tliat  undue  relaxa- 
tion will  not  recur.  The  powerful  influence  of  friction  in  promoting 
contraction  cannot  be  doubted,  and  nothing  will  replace  it ;  no  doubt 
it  is  fatiguing,  but  as  iong  as  it  is  effectual  it  must  be  kept  up.  No 
roughness  should  be  used,  as  we  might  produce  subsequent  injury, 
but  it  is  quite  possible  to  use  considerable  pressure  without  any 
violence. 

Another  method  of  applying  uterine  pressure  has  been  strongly 
advocated  by  Dr.  Hamilton,  of  Falkirk,  and  it  may  be  serviceable 
where  there  is  a  constant  draining  from  the  uterus,  and  a  capacious 
pelvis.  It  consists  in  passing  the  fingers  of  the  right  hand  high  up 
in  the  posterior  cul-de-sac  of  the  vagina,  so  as  to  reach  the  posterior 
surface  of  the  uterus,  while  counter-pressure  is  exercised  by  the  left 
hand  through  the  abdomen.  The  anterior  and  posterior  walls  of  the 
uterus  are  thus  closely  pressed  together. 

Administration  of  Ergot. — During  the  time  that  pressure  is  being 
applied,  attention  can  be  paid  to  general  treatment;  and  in  giving 
his  directions  to  the  by-standers  the  practitioner  should  be  calm  and 
collected,  avoiding  all  hurry  and  excitement.  A  full  dose  of  ergot 
should  be  adminstered,  and  if  one  have  alreadj^  been  given,  it  should 
be  repeated.  We  cannot,  however,  look  upon  ergot  as  anything  but 
a  useful  accessory,  and  it  is  one  which  requires  considerable  time  to 
operate.  The  hypodermic  use  of  ergotine  offers  the  double  advan- 
tage, in  severe  cases,  of  acting  with  greater  power,  and  much  more 
rapidly  than  the  usual  method  of  administration.  It  should,  there- 
fore, always  be  used  in  preference. 

Stimulants. — The  sudden  flow  will  probably  have  produced  ex- 
haustion and  a  tendency  to  syncope,  and  the  administration  of  stimu- 
lants will  be  necessary.  The  amount  must  be  regulated  by  the  state 
of  the  pulse,  and  the  degree  of  exhaustion.  There  is  no  more  ab- 
surd mistake,  however,  than  implicitly  relying  on  the  brandy  bottle 
to  check  post-partum  hemorrhage.  In  the  worst  cases  absorption  is 
in  abeyance,  and  brandy  may  be  poured  down  in  abundance,  the  prac- 
titioner believing  that  he  is  rousing  his  patient,  while  he  is,  in  fact, 
only  filling  the  stomach  with  a  quantity  of  fluid,  which  is  eventu- 
ally thrown  up  unaltered.  I  have  more  than  once  seen  symptoms, 
produced  by  the  over-free  use  of  brandy  in  slight  floodings,  which 
were  certainly  not  those  of  hemorrhage.  I  remember  on  one  occa- 
sion being  summoned  by  a  practitioner,  with  a  view  to  transfusion, 
to  a  patient  who  was  said  to  be  insensible  and  collapsed  from  hemor- 
rhage._  I  found  her,  indeed,  unconscious ;  but  with  a  flushed  face,  a 
bounding  pulse,  a  firmlv  contracted  uterus,  and  deep  stertorous 
breathing.  On  inquiry  I  ascertained  that  she  had  taken  an  enor- 
mous quantity  of  brandy,  Avhich  had  brought  on  the  coma  of  pro- 
found intoxication,  while  the  hemorrhage  had  obviously  never  been 
excessive. 

Hypodermic  Injection  of  Ether. — The  hypodermic  injection  of  sul- 
phuric ether  has  been  recommended  as  a  powerful  stimulant  in 
cases  in  which  exhaustion  is  very  great.     A  fluidrachm  may  be  in- 


HEMORRHAGE    AFTER    DELIVERY.  417 

jected,  and  the  remedy  is  worthy  of  trial,  when  the  tendency  to  syn- 
cope is  extreme. 

Fresh  Air,  etc. — The  windows  should  be  thrown  widely  open,  to 
allow  a  current  of  fresh  cold  air  to  circulate  freely  through  the  room. 
The  pillows  should  be  removed,  the  head  kept  low,  and  the  patient 
should  be  assiduously  fanned. 

EmiotyirKj  of  Uterus. — If  bleeding  continue,  or  if  it  commence  be- 
fore the  placenta  is  expelled,  the  hand  should  be  carefully  and  gently 
passed  into  the  uterus,  and  its  cavity  cleared  of  its  contents.  The 
mere  presence  of  the  hand  within  the  uterus  is  a  powerful  incitor  of 
uterine  action.  When  the  placenta  is  retained  it  is  the  more  essen- 
tial, as  the  hemorrhage  cannot  possibly  be  checked  as  long  as  the  ■ 
uterus  is  distended  by  it.  During  the  operation  the  uterus  should 
be  supported  by  the  left  hand  externally,  and,  by  using  the  two 
hands  in  concert,  the  chances  of  injuring  the  textures  are  greatly 
lessened. 

Treatment  of  Hour-glass  Contraction. — -If  the  so-called  "  hour-glass 
contraction*'  be  present,  or  if  the  placenta  be  morbidly  adherent,  the 
operation  will  be  more  difficult,  and  will  require  much  judgment  and 
care.  The  spasmodic  contraction  of  the  inner  os  in  the  former  case 
may  generally  be  overcome  by  gentle  and  continuous  pressure  of  the 
fingers  passed  within  the  contraction,  while  the  uterus  is  supported 
from  without.  By  this  means,  too,  further  hemorrhage  can  in  most 
cases  be  controlled,  until  the  spasm  is  sufficiently  relaxed  to  admit  of 
the  passage  of  the  hand. 

Signs  of  Adherent  Placenta. — There  are  no  very  reliable  signs  to 
indicate  morbid  adhesion  of  the  placenta,  previous  to  the  introduc- 
tion of  the  hand.  The  following  are  the  symptoms  as  laid  down  by 
Barnes,  any  of  which  might,  however,  accompany  non-detachment  of 
the  placenta,  unaccompanied  by  adhesion  :  "  You  may  suspect  mor- 
bid adhesion,  if  there  have  been  unusual  difficulty  in  removing  the 
placenta  in  previous  labors ;  if,  during  the  third  stage,  the  uterus 
contracts  at  intervals  firmly,  each  contraction  being  accompanied  by 
blood,  and  yet,  on  following  up  the  cord,  you  feel  the  placenta  in 
utero  ;  if  on  pulling  on  the  cord,  two  fingers  being  pressed  into  the 
placenta  at  the  root,  you  feel  the  placenta  and  uterus  descend  in  one 
mass,  a  sense  of  dragging  pain  being  elicited ;  if,  during  a  pain  the 
uterine  tumor  does  not  present  a  globular  form,  but  be  more  promi- 
nent than  usual  at  the  place  of  placental  attachment."^ 

Treatment  of  Adherent  Placenta. — The  artificial  removal  of  an  ad- 
herent placenta  is  always  a  delicate  and  anxious  operation,  which, 
however  carefully  performed,  must  of  necessity  expose  the  patient 
to  the  risk  of  injury  to  the  uterine  structures,  and  of  leaving  behind 
portions  of  placental  tissue,  which  may  give  rise  to  secondary  hemor- 
rhage, or  septicaemia.  The  cord  will  guide  the  hand  to  the  site  of 
attachment,  and  the  fingers  must  be  very  gently  insinuated  between 
the  lower  edge  of  tlie  placenta  and  the  uterine  wall ;  or,  if  a  portion 
be  already  detached,  we  may  commence  to  peel  off  the  remainder  at 

'  Obstetric  Operations,  p.  440. 


418  LABOR. 

that  spot.  Supporting  the  uterus  externally,  we  carefully  pick  off  as 
much  as  possible,  proceeding  with  the  greatest  caution,  as  it  is  bj  no 
means  easy  to  distmguish  between  the  placenta  and  the  uterus.  At 
the  best  it  is  far  from  easy  to  remove  all,  and  it  is  wiser  to  separate 
only  what  we  readily  can,  than  to  make  too  protracted  efforts  at  com- 
plete detachment.  When  it  is  found  to  be  impossible  to  detach  and 
remove  the  whole,  or  a  great  part  of  the  placenta,  we  cannot  but 
look  upon  the  further  progress  of  the  case  with  considerable  anxiety. 
The  retained  portions  may  be,  ere  long,  spontaneously  detached  and 
expelled,  or  they  may  decompose  and  give  rise  to  fetid  discharge 
and  septic  infection.  Such  cases  must  be  treated  by  antiseptic  intra- 
uterine injections,  so  as  to  lessen  the  risk  of  absorption  as  much  as 
possible  ;  but  until  the  retained  masses  have  been  expelled,  and  the 
discharge  has  ceased,  the  patient  must  be  considered  to  be  in  consider- 
able danger.  In  a  few  rare  cases,  there  is  reason  to  believe  that 
considerable  masses  of  retained  placental  tissue  have  been  entirely 
absorbed.  It  is  difficult  to  understand  so  strange  a  phenomenon, 
but  several  well-authenticated  cases  are  recorded,  in  which  there 
seems  no  reason  to  doubt  that  the  retained  placenta  was  removed  in 
this  way.^ 

[The  placenta  7)%ay  he  retained  for  a  long  period^  and  finally  be  sus- 
pected of  being  a  malignant  growth.  I  saw  one  case  recently  in  which 
the  uterus  had  been  inverted  for  three  years  and  had  a  mass  like  a 
malignant  growth  upon  its  fundus.  When  etherized,  and  placed  in 
the  knee-chest  position,  the  uterus  replaced  itself,  as  soon  as  air  was 
introduced  into  the  vagina, — Ed.] 

Excitement  of  Reflex  Action  hy  Gold^  etc. — Various  means  are  used 
for  exciting  uterine  contraction  by  reflex  stimulation.  Amongst  the 
most  important  of  these  is  cold.  In  patients  who  are  not  too  ex- 
hausted to  respond  to  the  stimulus  applied,  it  is  of  extreme  value. 
But,  to  be  of  use,  it  should  be  used  intermittently,  and  not  continu- 
ously. Pouring  a  stream  of  cold  water  from  a  height  on  the  abdomen 
is  a  not  uncommon,  but  bad,  practice,  as  it  deluges  the  patient  and 
the  bedding  in  water,  AAdiich  may  afterwards  act  injuriously.  Flap- 
ping the  lower  part  of  the  abdomen  with  a  wet  towel  is  less  objec- 
tionable. Ice  can  generally  be  obtained,  and  a  piece  should  be  in- 
troduced into  the  uterus.  This  is  a  very  powerful  hcemostatic,  and 
often  excites  strong  action  when  other  means  fail.  I  constantly  em- 
ploy it,  and  have  never  seen  any  bad  results  follow.  A  large  piece 
of  ice  may  also  be  held  over  the  fundus,  and  removed,  and  re-applied 
from  time  to  time.  Iced  water  may  be  injected  into  the  rectum.  A 
very  powerful  remedy  is  washing  out  the  uterine  cavity  with  a 
stream  of  cold  water,  by  means  of  the  vaginal  pipe  of  a  Iligginson's 
syringe  carried  up  to  the  fundus.  Another  means  of  applying  cold, 
said  to  be  very  effectual,  is  the  application  of  the  ether  spray,  such  as 
is  used  for  producing  local  anaesthesia,  over  the  lower  part  of  the 
abdomen.^     All  these  remedies,  however,  depend  for  their  good  re- 

•  See  an  interesting  paper  by  Dr.  Thrusli  on  "  Retention  of  the  Placenta  in  Labor 
at  Term."     Am.  Journ.  of  Obstet.,  .July,  1877. 
2  Griffiths,  Practitioner,  March,  1877. 


HEMORRHAGE    AFTER    DELIVERY.  419 

suits  on  the  fact  of  the  patient  being  in  a  condition  to  respond  to 
stimulus ;  and  their  prolonged  use,  if  they  fail  to  excite  contraction 
rapidly,  will  certainly  prove  injurious.  Kigby  used  to  look  upon  the 
application  of  the  child  to  the  breast  as  one  of  the  most  certain  in- 
citors  of  uterine  action.  It  may  be  of  service,  after  the  hemor- 
rhage has  been  checked,  in  keeping  up  tonic  contraction,  and  should 
therefore  not  be  omitted ;  but  we  certainly  cannot  waste  time  in  in- 
ducing the  child  to  suck  in  the  face  of  the  actual  emergency. 

Intra-uterine  Injections  of  Warm  Water. — Of  late,  intra-uterine  in- 
jections of  warm  water,  at  a  temperature  of  from  100^  to  120^  have 
been  highly  recommended  as  a  powerful  means  of  arresting  post- 
partum hemorrhage,  often  proving  effectual  when  all  other  treatment 
has  failed.  The  number  of  published  cases  in  which  it  has  proved 
of  great  value  is  now  considerable.  The  present  master  of  the 
Eotunda,  Dr.  Lombe  Atthill,  has  recorded  16  cases^  in  which  it 
checked  hemorrhage  at  once,  in  many  of  which  ergot,  ice,  and  other 
means  had  failed.  He  speaks  of  it  as  especially  useful  in  those 
troublesome  cases  in  which  the  uterus  alternately  relaxes  and 
hardens,  and  resists  all  our  efforts  to  produce  permanent  contraction. 
My  own  experience  of  this  treatment  is  very  favorable.  I  have  now 
used  it  in  several  cases,  in  some  of  which  the  tendency  to  hemor- 
rhage was  very  great,  and  in  every  instance  it  has  at  once  produced 
strong  uterine  action,  and  instantly  checked  the  flow.  It  is,  more- 
over, much  more  agreeable  to  the  patient  than  cold  applications.  I 
think  it  cannot  be  doubted  that  we  have  in  these  warm  irrigations  a 
valuable  addition  to  our  methods  of  treating  uterine  hemorrhage. 

State  of  the  Bladder. — The  late  Dr.  Earle  pointed  out^  that  a  dis- 
tended bladder  often  prevents  contraction,  and  to  avoid  the  possi- 
bility of  this  the  catheter  should  be  passed. 

Plugging  of  the  Vagina. —  Plugging  of  the  vagina  has  often  been 
used.  It  is  only  necessary  to  mention  it  for  the  purpose  of  insisting 
on  its  absolute  inapplicability  in  all  cases  of  post-partum  hemorrhage  ; 
the  only  effect  it  could  have  would  be  to  prevent  the  escape  of  blood 
externall}^,  which  might  then  collect  to  any  extent  in  the  cavity  of 
the  uterus, 

Comj^ression  of  the  dlxlominal  aorta  is  highly  thought  of  by  many 
continental  authorities,  but  is  little  known  or  practised  in  this 
country.  It  has  been  objected  to  by  some  on  the  theoretical  ground 
that  the  hemorrhage  is  chiefly  venous,  and  not  arterial,  and  that  it 
would  only  favor  the  reflux  of  venous  blood  into  the  vena  cava. 
Cazeaux  points  out  that,  on  account  of  the  close  anatomical  relations 
between  the  aorta  and  the  vena  cava,  it  is  hardly  possible  to  compress 
one  vessel  without  the  other.  The  backward  flow  of  blood,  therefore, 
through  the  vena  cava  may  also  be  thus  arrested.  There  is  strong 
evidence  in  favor  of  the  occasional  utility  of  compression.  Its  chief 
recommendation  is,  that  it  can  be  practised  immediately,  and  by  an 
assistant  who  can  be  shown  how  to  apply  the  pressure.     It  is  most 

'  Lancet,  February  9,  1878. 

2  Earle's  Flooding  after  Delivery,  p.  1G3. 


420  LABOR. 

likely  to  prove  useful  in  sudden  and  severe  hemorrhage,  and,  if  it 
only  control  the  loss  for  a  few  moments,  it  gives  us  time  to  apply 
other  methods  of  treatment.  As  a  temporary  expedient,  therefore, 
it  should  be  borne  in  mind,  and  adopted  when  necessary.  It  has 
the  great  advantage  of  supplementing,  without  superseding,  other 
and  more  radical  plans  of  treatment.  The  pressure  is  very  easily 
applied,  on  account  of  the  lax  state  of  the  abdominal  walls.  The 
artery  can  readily  be  felt  pulsating  above  the  fundus  uteri,  and  can 
be  compressed  against  the  vertebra  by  three  or  four  fingers  applied 
lengthways.  Baudelocque,  who  was  a  strong  advocate  of  this  pro- 
cedure, states  that  he  has,  on  several  occasions,  controlled  an  other- 
wise intractable  hemorrhage  in  this  way,  and  that  he,  on  one  occasion, 
kept  up  compression  for  four  consecutive  liours.  Cazeaux  believes 
that  compression  of  the  aorta  may  have  a  further  advantageous  effect 
in  retaining  the  mass  of  the  blood  in  the  upper  part  of  the  body,  and 
thus  lessening  the  tendency  to  syncope  and  collapse.  If  an  aortic 
tourniquet,  such  as  is  used  for  compressing  the  vessel  in  cases  of 
aneurism,  could  be  obtained,  it  might  be  used  with  advantage  in 
serious  cases. 

Bandaying  of  the  Extremities. — "When  the  hemorrhage  has  been 
excessive,  and  there  is  profound  exhaustion  firm  bandaging  of  the 
extremities,  by  preference  with  Esmarch's  elastic  bandages  if  they 
can  be  obtained,  may  be  advantageously  adopted,  with  the  view  of 
retaining  the  blood  as  much  as  possible  in  the  trunk,  and  thus  lessen- 
ing the  tendency  to  syncope.  As  a  temporary  expedient  in  the 
worst  class  of  cases  it  may  occasionally  prove  of  service. 

Infection  of  Styptics. — Supposing  these  means  fail,  and  the  uterus 
obstinately  refuses  to  contract  in  spite  of  all  our  efforts — and,  do 
what  we  may,  cases  of  this  kind  will  occur — the  only  other  agent  at 
our  command  is  the  application  of  a  powerful  styptic  to  the  bleeding 
surface  to  produce  thrombosis  in  the  vessels.  "  The  latter,"  says  Dr. 
Ferguson,^  alluding  to  this  means  of  arresting  hemorrhage,  "  appears 
to  be  the  sole  means  of  safety  in  those  cases  of  intense  flooding  in 
whicli  the  uterus  flaps  about  the  hand  like  a  wet  towel.  Incapable 
of  contraction  for  hours,  yet  ceasing  to  ooze  out  a  drop  of  blood, 
there  is  ■  nothing  apparently  between  life  and  death  but  a  few  soft 
coagula  plugging  up  the  sinuses."  These  form  but  a  frail  barrier 
indeed,  but  the  experience  of  all  who  have  used  the  injection  of  a 
solution  of  perchloride  of  iron  in  such  cases,  proves  that  they  are 
thoroughly  effectual,  and  its  introduction  into  practice  is  one  of  the 
greatest  improvements  in  modern  midwifery.  Although  this  method 
of  treating  these  obstinate  cases  is  not  new,  since  it  was  practised 
long  ago  in  Germany,  its  adoption  in  this  country  is  unquestionably 
due  to  the  energetic  recommendation  of  Dr.  Barnes.  Although  the 
dangers  of  the  practice  have  been  strongly  insisted  on,  and  with  a 
degree  of  acrimony  that  is  to  be  regretted,  I  know  of  only  one  pub- 
lished case  in  which  its  use  has  been  followed  by  any  evil  effects. 
Its  extraordinary  power,  however,  of  instantly  checking  the  most 

1  Preface  to  Goocli  Ou  Diseases  of  Women,  p.  slii. 


HEMORRHAGE    AFTER    DELIVERY.  421 

formidable  hemorrhage,  has  been  demonstrated  by  the  unanimous 
testimony  of  all  who  have  tried  it.  As  it  is  not  proposed  by  any  one 
that  this  means  of  treatment  should  be  employed  until  all  ordinary 
methods  of  evoking  contraction  have  failed,  and  as,  in  cases  of  this 
kind,  the  lives  of  the  patients  are  of  necessity  imperilled,  we  should 
be  fully  justified  in  adopting  it,  even  if  its  possible  injurious  effects 
had  been  much  more  certainly  proved.  It  is  surely  at  any  time 
justifiable  to  avoid  a  great  and  pressing  peril  by  running  a  possible 
chance  of  a  less  one.  Whenever,  therefore,  we  have  tried  the  plans 
above  indicated  in  vain,  no  time  should  be  lost  in  resorting  to  this 
expedient.  No  practitioner  should  attend  a  case  of  midwifery  with- 
out having  the  necessary  styptic  with  him.  The  best  and  most 
easily  obtainable  form  of  using  the  remedy  is  the  "liquor  ferri  per- 
chloridi  fortior"  of  the  London  Pharmacopoeia,  which  should  be 
diluted  for  use  with  six  times  its  bulk,  of  w^ater.  This  is  certainly 
better  than  a  weaker  solution.  The  vaginal  pipe  of  a  Higginson's 
syringe,  through  which  the  solution  has  once  or  twice  been  pumped 
to  exclude  the  air,  is  guided  by  the  hand  to  the  fundus  uteri,  and 
the  fluid  injected  gently  over  the  uterine  surface.  The  loose  and 
flabby  mucous  membrane  is  instantaneously  felt  to  pucker  up,  all 
the  blood  with  which  the  fluid  comes  in  contact  is  coagulated  and 
the  hemorrhage  is  immediately  arrested.  I  think  it  is  of  importance 
to  make  sure  that  the  uterus  and  vagina  are  emptied  of  clots  before 
injection.  In  the  only  cases  in  which  I  have  seen  any  bad  symptoms 
follow,  this  precaution  had  been  neglected.  The  iron  hardened  all 
the  coagula,  which  remained  in  utero,  and  septic£emia  supervened ; 
which,  however,  disappeared  after  the  clots  had  been  broken  up  and 
washed  away  by  intra-uterine  antiseptic  injections.  After  we  have 
resorted  to  this  treatment,  all  further  pressure  on  the  uterus  should 
be  stopped.  We  must  remember  that  we  have  now  abandoned  con- 
traction as  an  h£emostatic,  and  are  trusting  to  thrombosis,  and  that 
pressure  might  detach  and  lessen  the  coagula  which  are  preventing 
the  escape  of  blood. 

Other  local  astringents  may  be  eventually  found  to  be  of  use. 
Tincture  of  matico  possibly  might  be  serviceable,  although  I  am  not 
aware  that  it  has  been  tried.  Dupierris  has  advocated  tincture  of 
iodine,  and  has  recorded  2-i  cases  in  which  he  employed  it,  in  all 
without  accident  and  with  a  successful  issue.  Penrose  strongly  re- 
commends common  vinegar,  which  has  the  advantage  of  being  always 
readily  obtainable.  But  nothing  seems  likely  to  act  so  immediately 
or  so  effectually,  as  the  perchloride  of  iron. 

HemorrhcKje  from  Laceration  of  Maternal  Structures. — A  word  may 
here  be  said  as  to  the  occasional  dependence  of  hemorrhage  after 
delivery  on  laceration  of  the  cervix,  or  other  injury  to  the  maternal 
soft  parts.  Duncan  has  narrated  a  case  in  which  the  bleeding  came 
from  a  ruptured  perineum.  If  hemorrhage  continue  after  the  uterus 
is  permanently  contracted,  a  careful  examination  should  be  made 
to  ascertain  if  any  such  injury  exist.  Most  generally  the  source  of 
bleeding  is  the  cervix,  and  the  flow  can  be  readily  arrested  by  swab- 


422  LABOR. 

bing  tLe  injured  textures  with  a  sponge  saturated  in  a  solution  of 
the  percliloride. 

Secondary  Treatment. — The  secondary  treatment  of  post-partum 
hemorrhage  is  of  importance.  When  reaction  commences,  a  train 
of  distressing  symptoms  often  show  themselves,  such  as  intense  and 
throbbing  headache,  great  intolerance  of  light  and  sound,  and  general 
nervous  prostration  ;  and,  when  these  have  passed  away,  we  have  to 
deal  with  the  more  chronic  effects  of  profuse  loss  of  blood.  Nothing 
is  so  valuable  in  relieving  these  symptoms  as  opium.  It  is  the  best 
restorative  that  can  be  employed,  but  it  must  be  administered  in 
larger  doses  than  usual.  Thirty  to  forty  drops  of  Battley's  solution 
should  be  given  by  the  mouth,  or  in  an  enema.  At  the  same  time 
the  patient  should  be  kept  perfectly  still  and  quiet,  in  a  darkened 
room,  and  the  visits  of  anxious  friends  strictly  forbidden.  Strong 
beef  essence  or  gravy  soup,  milk,  or  eggs  beat  up  with  milk,  and 
similar  easily  absorbed  articles  of  diet,  should  be  given  frequently, 
and  in  small  quantities  at  a  time.  Stimulants  will  be  required  ac- 
cording to  the  state  of  the  patient,  such  as  warm  brandy  and  water, 
port  wine,  etc.  Eest  in  bed  should  be  insisted  on,  and  continued 
much  beyond  the  usual  time.  Eventually  the  remedies  which  act 
by  promoting  the  formation  of  blood,  such  as  the  various  prepara- 
tions of  iron,  will  be  found  useful,  and  may  be  required  for  a  length 
of  time. 

Transfusion. — Under  the  head  of  transfusion  I  have  separately 
treated  the  application  of  that  last  resource  in  those  desperate  cases 
in  which  the  loss  of  blood  has  been  so  excessive  as  to  leave  no  other 
hope. 

Secondary  Post-partum  Hemorrhage. — In  the  majority  of  cases,  if 
a  few  hours  have  elapsed  after  delivery  without  hemorrhage,  we  may 
consider  the  patient  safe  from  the  accident.  It  is  by  no  means  very 
rare,  however,  to  meet  with  even  profuse  losses  of  blood  coming  on 
in  the  course  of  convalescence,  at  a  time  varying  from  a  few  hours, 
or  days,  up  to  several  weeks  after  delivery.  These  cases  are  de- 
scribed as  examples  of  ^'' secondary  hemorrharje^''''  and  they  have  not 
received  at  all  an  adequate  amount  of  attention  from  obstetric 
writers,  inasmuch  as  they  often  give  rise  to  very  serious,  and  even 
fatal,  results,  and  are  always  somewhat  obscure  in  their  etiology, 
and  difficult  to  treat.  We  owe  almost  all  our  knowledge  of  this 
condition  to  an  excellent  paper  by  Dr.  McClintock,  of  Dublin,  who 
has  collected  characteristic  examples  from  the  writings  of  various 
authors,  and  accurately  described  the  causes  which  are  most  apt  to 
produce  it. 

Profuse  Lochial  Discharrje. — We  must,  in  the  first  place,  distin- 
guish between  true  secondary  hemorrhage  and  profuse  lochial  dis- 
charge, continued  for  a  longer  time  than  usual.  The  latter  is  not  a 
very  uncommon  occurrence,  and  is  generally  met  with  in  cases  in 
which  involution  of  the  uterus  has  been  checked ;  as  by  too  early 
exertion,  general  debility,  and  the  like.  The  amount  of  the  lochial 
discharge  varies  in  different  women.  In  some  patients  it  habitually 
continues  during  the  whole  puerperal  month,  and  even  longer,  but 


HEMORRHAGE    AFTER    DELIVERY.  423 

not  to  an  extent  winch  justifies  us  in  including  it  under  the  head  of 
hemorrhage.  In  such  cases  prolonged  rest,  avoidance  of  the  erect 
posture,  occasional  small  doses  of  ergot,  and,  it  may  be,  after  the 
lapse  of  some  weeks,  astringent  injections  of  oak  bark,  or  alum,  will 
be  all  that  is  necessary  in  the  way  of  treatment. 

True  secondary  hemorrhage  is  often  sudden  in  its  appearance  and 
serious  in  its  eft'ects.  McClintock  mentions  6  fatal  cases,  and  Mr. 
Bassett,  of  Birmingham,^  has  recorded  13  examples  which  came 
under  his  own  observation,  2  of  which  ended  fatally. 

The  Causes  are  either  Constitutional  or  Local. — The  causes  may  be 
either  constitutional,  or  some  local  condition  of  the  uterus  itself. 

Among  the  former  are  such  as  produce  a  disturbance  of  the  vascu- 
lar system  of  the  body  generally,  or  of  the  uterine  vessels  in  particu- 
lar. The  state  of  the  uterine  sinuses,  and  the  slight  barrier  which 
the  thrombi  formed  in  them  offer  to  the  escape  of  blood,  readily 
explain  the  fact  of  any  sudden  vascular  congestion  producing  hemor- 
rhage. Thus  mental  emotions,  the  sudden  assumption  of  the  erect 
posture,  any  undue  exertion,  the  incautious  use  of  stimulants,  a 
loaded  condition  of  the  bowels,  or  sexual  intercourse  shortly  after 
delivery,  may  act  in  this  way.  McClintock  records  the  case  of  a 
lady  in  whom  very  profuse  hemorrhage  occurred  on  the  twelfth  day 
after  labor,  when  sitting  up  for  the  first  time.  Feeling  faint  after 
suckling,  the  nurse  gave  her  some  brandy,  whereupon  a  gush  of 
blood  ensued,  "deluging  all  the  bed-clothes  and  penetrating  through 
the  mattress  so  as  to  form  a  pool  on  the  floor."  Here  the  erect  posi- 
tion, the  exquisite  pain  caused  by  nursing,  and  the  stimulating  drink, 
all  concurred  to  excite  the  hemorrhage.  In  another  instance  the 
flooding  was  traced  to  excitement  produced  by  the  sudden  return 
of  an  old  lover  on  the  eighth  day  after  labor.  Moreau  especially 
dwells  on  the  influence  of  local  congestion  produced  by  a  loaded  con- 
dition of  the  rectum.  Constitutional  affections  producing  general 
debility,  and  an  impoverished  state  of  the  blood,  probably  also  may 
have  the  same  effect.  Blot  specially  mentions  albuminuria  as  one  of 
these,  and  Saboia  states  that  in  Brazil  secondary  hemorrhage  is  a 
common  symptom  of  miasmatic  poisoning,  and  can  only  be  cured  by 
change  of  air  and  the  free  use  of  quinine.^ 

Local  Causes. — Local  conditions  seem,  however,  to  be  more  fre- 
quent factors  in  the  production  of  secondary  hemorrhage.  Thesis 
may  be  generally  classed  under  the  following  heads : — 

1.  Irregular  and  inefficient  contraction  of  the  uterus, 

2.  Clots  in  the  uterine  cavity. 

3.  Portions  of  retained  placenta  or  membranes. 

4.  Eetroflexion  of  the  uterus. 

5.  Laceration  or  inflammatory  state  of  the  cervix. 

6.  Thrombosis  or  hematocele  of  the  cervix  or  vulva. 

7.  Inversion  of  the  uterus. 

8.  Fibroid  tumors  or  polypus  of  the  uterus. 

«  Brit.  Med.  Jour.,  1872. 

2  Saboia,  Trait6  des  Accouchements.  p.  819. 


421  LABOR. 

The  first  four  of  these  need  only  now  be  considered,  the  others 
being  described  elsewhere. 

Relaxation  of\  and  Clots  in,  the  Uterus. — Relaxation  of  the  uterus 
and  distension  of  its  cavity  by  coagula  may  give  rise  to  hemorrhage, 
although  not  so  readily  as  immediately  after  delivery,  for  coagula  of 
considerable  size  are  often  retained  in  utero  for  many  days  after 
labor.  The  uterus  will  be  found  larger  than  it  ought  to  be,  and 
tender  on  pressure.  Usually  the  coagula  are  expelled  with  severe 
after-pains  ;  but  this  may  not  take  place,  and  hemorrhage  may  ensue 
several  days  after  delivery.  Or  there  may  be  only  a  relaxed  state 
of  the  uterus  without  retained  coagula.  Bassett  relates  4  cases  traced 
to  these  causes,  and  several  illustrations  will  be  found  in  McClin- 
tock's  paper.  Portions  of  retained  placenta  or  membranes  are  more 
frequeut  causes.  The  retention  may  be  due  to  carelessness  on  the 
part  of  the  practitioner,  especially  if  he  have  removed  the  placenta 
by  traction,  and  failed  to  satisfy  himself  of  its  integrity.  It  may, 
however,  often  be  due  to  circumstances  entirely  beyond  his  control; 
such  as  adherent  placenta,  which  it  is  impossible  to  remove  without 
leaving  portions  in  utero,  or  more  rarely  placenta  succenturia.  In 
the  latter  case  there  is  a  small  supplementary  portion  of  placental 
tissue  developed  entirely  separate  from  the  general  mass,  and  it  may 
remain  in  utero  without  the  practitioner  having  the  least  suspicion 
of  its  existence.  Portions  of  the  membranes  are  very  apt  to  be  left 
iu  utero.  It  is  to  prevent  this  that  they  should  be  twisted  into  a 
rope,  and  extracted  very  gently  after  expression  of  the  placenta. 
Hemorrhage  from  these  causes  generally  does  not  occur  until  at  least 
a  week  after  delivery,  and  it  may  not  do  so  until  a  much  longer  time 
has  elapsed.  In  4  cases,  recorded  by  Mr.  Bassett,  it  commenced  on 
the  twelfth,  tenth,  fourteenth,  and  thirty-second  day.  It  may  come 
on  suddenly  and  continue  ;  or  it  may  stop,  and  recur  frequently  at 
short  intervals.  In  my  experience  retention  of  portions  of  the  pla- 
centa is  very  common  after  abortion,  when  adhesions  are  more  gene- 
rally met  with  than  at  term.  In  addition  to  the  hemorrhage  there 
is  often  a  fetid  discharge,  due  to  decomposition  of  the  retained  por- 
tion, and  possibly  more  or  less  marked  septicemic  symptoms,  which 
may  aid  in  the  diagnosis.  The  placenta  or  membranes  may  simply 
be  lying  loose  as  foreign  bodies  in  the  uterine  cavity ;  or  they  may 
be  organically  attached  to  the  uterine  walls,  when  their  removal  will 
not  be  so  easily  effected. 

Retroflexion. — Barnes  has  especially  pointed  out  the  influence  of 
retroflexion  of  the  uterus  in  producing  secondary  hemorrhage,^  which 
seems  to  act  by  impeding  the  circulation  at  the  point  of  flexion,  and 
thus  arresting  the  process  of  involution. 

In  every  case  in  which  secondary  hemorrhage  occurs  to  any  extent, 
careful  investigation  into  the  possible  causes  of  the  attack,  and  an 
accurate  vaginal  examination,  are  imperatively  required.  If  it  be 
due  to  general  and  constitutional  causes  only,  we  must  insist  on  the 
most  absolute  rest  on  a  hard  bed  in  a  cool  room,  and  on  the  absence 

'  Obstetric  Operations,  p.  492. 


HEMORRHAGE    AFTER    DELIVERY.  425 

of  all  causes  of  excitement.  The  liquid  extract  of  ergot  will  be  very 
generally  useful  in  5j  doses  repeated  every  six  hours.  McCliutock 
strongly  recommends  the  tincture  of  Indian  hemp,  which  may  be  ad- 
vantageously combmed  with  the  ergot,  in  doses  of  10  or  15  minims, 
suspended  in  mucilage.  Astringent  vaginal  pessaries  of  matico  or 
perchloride  of  iron  may  be  used.  Special  attention  should  be  paid 
to  the  state  of  the  bowels,  and,  if  the  rectum  be  loaded,  it  should  be 
emptied  by  enemata.  In  more  chronic  cases  a  mixture  of  ergot, 
sulphate  of  iron,  and  small  doses  of  sulphate  of  magnesia,  will  prove 
very  serviceable.  This  is  more  likely  to  be  effectual  when  the  bleed- 
ing is  of  an  atonic  and  passive  character.  McCiintock  speaks  strongly 
in  favor  of  the  application  of  a  blister  over  the  sacrum.  When  the 
hemorrhage  is  excessive,  more  effectual  local  treatment  will  be  re- 
quired. Cazeaux  advises  plugging  of  the  vagina.  Although  this 
cannot  be  considered  so  dangerous  as  immediately  after  deliver}-, 
inasmuch  as  the  uterus  is  not  so  likely  to  dilate  above  the  plug, 
still  it  is  certainly  not  entirely  without  risk  of  favoring  concealed 
internal  hemorrhage.  If  it  be  used  at  all,  a  firm  abdominal  pad 
should  be  applied,  so  as  to  compress  tlie  uterus ;  and  the  abdomen 
should  be  examined,  from  time  to  time,  to  insure  against  the  possi- 
bility of  uterine  dilatation.  With  tbese  precautions  the  plug  may 
prove  of  real  value.  In  any  case  of  really  alarming  hemorrhage  I 
should  be  disposed  rather  to  trast  to  the  application  of  stj'ptics  to 
the  uterine  cavity.  The  injection  of  fluid  in  bulk,  as  after  delivery, 
could  not  be  safely  practised,  on  account  of  the  closure  of  the  os  and 
the  contraction  of  the  uterus.  But  there  can  be  no  objection  to 
swabbing  out  the  uterine  cavity  with  a  small  piece  of  sponge  attached 
to  a  handle,  and  saturated  in  a  solution  of  the  perchloride  of  iron. 
There  are  few  cases  which  will  resist  this  treatment. 

If  we  have  reason  to  suspect  retained  placenta  or  membranes,  or 
if  the  hemorrhage  continue  or  recur  after  treatment,  a  careful  ex- 
ploration of  the  interior  of  the  womb  will  be  essential.  On  vaginal 
examination,  we  may  possibly  feel  a  portion  of  the  placenta  protrud- 
ing through  the  os,  which  can  then  be  removed  without  difficulty. 
If  the  OS  be  closed,  it  must  be  dilated  with  sponge  or  laminaria  tents, 
or  by  a  small-sized  Barnes's  bag,  and  the  uterus  can  then  be  thoroughly 
explored.  This  ought  to  be  done  under  chloroform,  as  it  cannot  be 
effectually  accomplished  without  introducing  the  whole  hand  into 
the  vagina,  which  necessarily  causes  much  pai-n.  If  the  placenta  or 
membranes  be  loose  in  the  uterine  cavity,  they  may  be  removed  at 
once ;  or,  if  they  be  organically  attached,  they  may  be  carefully 
picked  off.  The  uterus  should  at  the  same  time,  and  as  long  as  the 
OS  remains  patulous,  be  thoroughly  washed  out  with  Condj^'s  fluid 
and  water,  to  diminish  the  risk  of  septicsemia. 

Eetroflexion  can  readily  be  detected  by  vaginal  examination,  and 
the  treatment  consists  in  careful  reposition  with  the  hand,  and  the 
application  of  a  large-sized  Hodge's  pessary. 

[In  managing  the  convalescence  after  excessive  hemorrhage  it  is 
of  great  importance  to  replace  the  loss  as  rapidly  as  possible,  in  order 
to  avoid  serious  diseases  resulting  from  exhaustion.  To  accomplish 
28 


426  LABOR. 

this,  I  am  iisually  in  tlie  habit  of  giving  the  essence  of  from  three 
to  seven  pounds  of  beef  per  diem,  for  the  first  two  weeks,  and  have 
given  as  high  as  eleven.  It  is  remarlcable  how  soon  this  restores  the 
health  and  strength  of  the  woman. — Ed.] 


CHAPTEE  XYI. 

EUPTURE  OF  THE  UTERUS,  ETC. 

EuPTUEE  of  the  uterus  is  one  of  the  most  dangerous  accidents  of 
labor,  and  until  of  late  years  it  has  been  considered  almost  necessarily 
fatal,  and  beyond  the  reach  of  treatment.  Fortunately  it  is  not  of 
very  frequent  occurrence,  although  the  published  statistics  vary  so 
much  that  it  is  by  no  means  easy  to  arrive  at  any  conclusion  on  this 
point.  The  explanation  is,  no  doubt,  that  many  of  the  tables  con- 
found partial  and  comparatively  unimportant  lacerations  of  the  cer- 
vix and  vagina,  with  rupture  of  the  body  and  fundus.  It  is  only  in 
large  lying-in  institutions,  where  the  results  of  cases  are  accurately 
recorded,  that  anything  like  reliable  statistics  can  be  gathered,  for 
in  private  practice  the  occurrence  of  so  lamentable  an  accident  is 
likely  to  remain  unpublished.  To  show  the  difference  between  the 
figures  given  by  authorities,  it  may  be  stated  that,  while  Burns  cal- 
culates the  proportion  to  be  1  in  940  labors,  Inglebv  fixes  it  as  1  in 
1300  or  1400,  Churchill  as  1  in  1331,  and  Lehmann  as  1  in  2433. 
Dr.  Jolly,  of  Paris,  has  published  an  excellent  thesis  containing  much 
valuable  information.^  He  finds  that  out  of  782,741  labors,  230  rup- 
tures, excluding  those  of  the  vagina  or  cervix,  occurred,  that  is,  1  in 
3403. 

Seat  of  Rupture. — -Lacerations  may  occur  in  any  part  of  the 
uterus — the  fundus,  the  body,  or  the  cervix.  Those  of  the  cervix 
are  comparatively  of  small  consequence,  and  occur,  to  a  slight  ex- 
tent, in  almost  all  first  labors.  Only  those  which  involve  the  supra- 
vaginal portion  are  of  really  serious  import.  Euptures  of  the  upper 
part  of  the  uterus  are  much  less  frequent  than  of  the  portion  near 
the  cervix ;  partly,  no  doubt,  because  the  fundus  is  beyond  the  reach 
of  the  mechanical  causes  to  which  the  accident  can,  not  unfrequently 
be  traced,  and  partly  because  the  lower  third  of  the  organ  is  apt  to 
be  compressed  between  the  presenting  part  and  the  bony  pelvis.  The 
site  of  placental  insertion  is  said  by  Madame  La  Chapelle  to  be  rarely 
involved  in  the  rupture,  but  it  does  not  always  escape,  as  numerous 
recorded  cases  prove.  The  most  frequent  seat  of  rupture  is  near  the 
junction  of  the  body  and  neck,  either  anteriorly  or  posteriorly,  op- 

•  Rupture  uterine  pendant  lo  Travail,  Paris,  1873. 


RUPTURE  OF  THE  UTERUS.  427 

posite  the  sacrum,  or  behind  the  symphysis  pubis,  but  it  may  occur 
at  the  sides  of  the  lower  segment  of  the  uterus.  In  some  cases 
the  entire  cervix  has  been  torn  away,  and  separated  in  tlie  form  uf 
a  ring. 

Rupture  may  he  Partial  or  Complete. — The  laceration  may  be 
partial  or  complete  ;  the  latter  being  the  more  common.  The  mus- 
cular, tissue  alone  may  be  torn,  the  peritoneal  coat  remaining  intact; 
or  the  converse  may  occur,  and  then  the  peritoneum  is  often  hssured 
in  various  directions,  the  musular  coat  being  unimplicated.  The 
extent  of  the  injury  is  very  variable:  in  some  cases  being  only  a 
slight  tear,  in  others  forming  a  large  aperture,  sufficiently  extensive 
to  allow  the  foetus  to  pass  into  the  abdominal  cavity.  The  direction 
of  the  laceration  is  as  variable  as  the  size,  but  it  is  more  frequently 
vertical  than  transverse  or  oblique.  The  edges  of  the  tear  are  irregu- 
lar and  jagged ;  probably  on  account  of  the  contraction  of  the  mus- 
cular fibres,  which  are  frequently  softened,  infiltrated  with  blood, 
and  even  gangrenous.  Large  quantities  of  extravasated  blood  will 
be  found  in  the  peritoneal  cavity ;  such  hemoiTliage,  indeed,  being 
one  of  the  most  important  sources  of  danger. 

Causes  are  either  Predisposing  or  Exciting. — The  causes  are  divided 
into  predisposing  and  exciting ;  and  the  progress  of  modern  research 
tends  more  and  more  to  the  conclusion  that  the  cause  which  leads  to 
the  laceration  could  only  have  operated  because  the  tissue  of  the 
uterus  was  in  a  state  predisposed  to  rupture,  and  that  it  would  have 
had  no  such  effect  on  a  perfectly  healthy  organ.  What  these  pre- 
disposing changes  are,  and  how  they  operate,  is  yet  far  from  being 
known,  and  the  subject  offers  a  fruitful  field  for  pathological  investi- 
gation. 

Said  to  le  m,ore  Common  in  Multiparse. — It  is  generally  believed 
that  lacerations  are  more  common  in  multiparas  than  in  primiparse. 
Tyler  Smith  contended  that  ruptures  are  relatively  as  common  in 
first  as  in  subsequent  labors.  Statistics  are  not  sufficiently  accurate 
or  extensive  to  justify  a  pt)sitive  conclusion,  but  it  is  reasonable  to 
suppose  that  the  pathological  changes,  presently  to  be  mentioned  as 
predisposing  to  laceration,  are  more  likely  to  be  met  with  in  women 
whose  uteri  have  frequently  undergone  the  alteration  attendant  on 
repeated  pregnancies.  Age  seems  to  have  considerable  influence,  as 
a  large  proportion  of  cases  have  occurred  in  women  between  thirty 
and  forty  years  of  age. 

Alteratio7is  in  the  tissues  of  the  uterus  are  probably  of  very  great 
importance  in  predisposing  to  the  accident,  although  our  information 
on  this  point  is  far  from  accurate.  Among  these  are  morbid  states 
of  the  muscular  fibres,  the  result  of  blows  and  contusions  during  preg- 
nancy; premature  fatty  degeneration  of  the  muscular  tissues,  an 
anticipation,  as  it  were,  of  the  normal  involution  after  delivery  ; 
fibroid  tumors,  or  malignant  infiltration  of  the  uterine  walls,  which 
either  produce  a  morbid  state  of  the  tissues,  or  act  as  an  impediment 
to  the  expulsion  of  the  foetus.  The  importance  of  such  changes  has 
been  specially  dwelt  on  by  Murphy  in  this  country,  and  by  Lehmann 
in  Germany,  and  it  is  impossible  not  to  concede  their  proi3able  influ- 


428  LABOR. 

ence  in  favoring  laceration.  However,  as  yet  tbese  views  are  founded 
more  on  reasonable  hypothesis  than  on  accurately  observed  patho- 
logical facts. 

Another  and  very  important  class  of  predisposing  causes  are  those 
which  lead  to  a  want  of  proper  proportion  between  the  pelvis  and 
the  foetus. 

Deformity  in  Pelvis  is  a  Frequent  Cause. — Deformity  of  the  pelvis 
has  been  very  frequently  met  with  in  cases  in  which  the  uterus  has 
ruptured.  Thus  out  of  19  cases,  carefully  recorded  by  Radford,^  the 
pelvis  was  contracted  in  11,  or  more  than  one-half.  Eadford  makes 
the  curious  observation  that  ruptures  seem  more  likely  to  occur 
when  the  deformity  is  only  slight ;  and  he  explains  this  by  supposing 
that  in  slight  deformities  the  lower  segment  of  the  uterus  engages 
in  the  brim,  and  is,  therefore,  much  subjected  to  compression,  while 
in  extreme  deformity  the  os  and  cervix  uteri  remain  above  the  brim, 
the  body  and  fundus  of  the  uterus  hanging  down  between  the  thighs 
of  the  mother.  This  explanation  is  reasonable  ;  but  the  rarity  with 
which  ruptured  uterus  is  associated  with  extreme  pelvic  deformity 
may  rather  depend  on  the  infrequency  of  advanced  degrees  of  con-  • 
traction. 

Malpresentation. — Amongst  causes  of  disproportion  depending  on 
the  foetus  are  either  malpresentation,  in  which  the  pains  cannot  effect 
expulsion,  or  undue  size  of  the  presenting  part.  In  the  latter  way 
may  be  explained  the  observation  that  rupture  is  much  more  fre- 
quently met  with  male  than  with  female  children,  on  account,  no 
doubt,  of  the  larger  size  of  the  head  in  the  former.  The  influence 
of  intra-uterine  hydrocephalus  was  first  prominently  pointed  out  by 
Sir  James  Simpson,^  who  states  that  out  of  74  cases  of  mtra-uterine 
hydrocephalus  the  uterus  ruptured  in  16.  In  all  such  cases  of  dis- 
proportion, whether  referable  to  the  pelvis  or  foetus,  rupture  is  pro- 
duced in  a  twofold  manner,  either  by  the  excessive  and  fruitless 
uterine  contractions,  which  are  induced  by  the  efforts  of  the  organ 
to  overcome  the  obstacle  ;  or  by  the  compression  of  the  uterine  tissue 
between  the  presenting  part  and  the  bony  pelvis,  leading  to  inflam- 
mation, softening,  and  even  gangrene. 

Mechanical  Injury  of  Bupture.—The  proximate  cause  of  rupture 
may  be  classed  under  two  heads — mechanical  injury,  and  excessive 
uterine  contraction.  Under  the  former  are  placed  those  uncommon 
cases  in  which  the  uterus  lacerates  as  the  result  of  some  injury  in 
the  latter  months  of  pregnancy,  such  as  blows,  falls,  and  the  like. 
Not  so  rare,  unfortunately,  are  lacerations  produced  by  unskilled 
attempts  at  delivery  on  the  part  of  the  medical  attendant,  such  as 
by  the  hand  during  turning,  or  by  the  blades  of  the  forceps.  Many 
such  cases  are  on  record,  in  which  the  accoucheur  has  used  force  and 
violence,  rather  than  skill,  in  his  attempts  to  overcome  an  obstacle. 
That  such  unhappy  results  of  ignorance  are  not  so  uncommon  as  they 
ought  to  be  is  proved  by  the  figures  of  Jolly,  who  has  collected  71 
cas'es  of  rupture  during  podalic  version,  37  caused  by  the  forceps,  10 

I  Obst.  Trans.,  vol.  viii.  2  Selected  Obst.  Works,  p.  385. 


RUPTURE  OF  THE  UTERUS.  429 

by  the  ceplialotribe,  and  30  during  otlier  operations,  the  precise  nature 
of  whicli  is  not  stated,'  Tiie  modus  operuyidi  of  protracted  and  in- 
eflectual  uterine  contractions,  as  a  proximate  cause  of  rupture,  is 
sufficiently  evident,  and  need  not  be  dwelt  on.  It  is  necessary  to 
allude,  however,  to  the  effect  of  ergot,  incautiously  administered,  as 
a  producing  cause.  There  is  abundant  evidence  that  the  injudicious 
exhibition  of  this  drug  has  often  been  followed  by  laceration  of  the 
unduly  stimulated  uterine  fibres.  Thus,  Traslc,  talking  of  the  sub- 
ject, says  that  Meigs  had  seen  three  cases,  and  Bedf()rd  four,  distinctly 
traceable  to  this  cause.  Jolly  found  that  ergot  had  been  administered 
largely  in  33  cases  in  which  rupture  occurred. 

Premonitory  Symptoms. — Some  have  believed  that  the  impending 
occurrence  of  rupture  could  frequently  be  ascertained  by  peculiar 
premonitory  symptoms,  such  as  excessive  and  acute  crampy  pains 
about  the  lower  part  of  the  abdomen,  due  to  the  compression  of  part 
of  the  uterine  wails.  These  are  far  too  indefinite  to  be  relied  on, 
and  it  is  certain  that  the  rupture  generally  takes  place  without  any 
symptoms  that  would  have  afforded  reasonable  grounds  for  suspicion. 

Oeiieral  Symptoms. — The  symptoms  are  often  so  distinct  and  alarm- 
ing as  to  leave  no  doubt  as  to  the  nature  of  the  case  ;  not  infrequently, 
however,  especially  if  the  laceration  be  partial,  they  are  by  no  means 
so  well  marked,  and  the  practitioner  may  be  uncertain  as  to  what 
has  taken  place.  In  the  former  class  of  cases  a  sudden  excruciating 
pain  is  experienced  in  the  abdomen,  generally  during  the  uterine 
contractions,  accompanied  by  a  feeling,  on  the  part  of  the  patient,  of 
something  having  given  way.  In  some  cases  this  has  been  accom- 
panied by  an  audible  sound,  which  has  been  noticed  by  the  by- 
standers. At  the  same  time  there  is  generally  a  considerable  escape 
of  blood  from  the  vagina,  and  a  prominent  symptom  is  the  sudden 
cessation  of  the  previously  strong  pains.  Alarming  general  symp- 
toms soon  develop,  partly  due  to  shock,  partly  to  loss  of  blood,  both 
external  and  internal.  The  face  exhibits  the  greatest  suffering,  the 
skin  becomes  deadly  cold  and  covered  with  a  clammy  sweat,  and 
fainting,  collapse,  rapid  feeble  pulse,  hurried  breathing,  vomiting, 
and  all  the  usual  signs  of  extreme  exhaustion  quickly  follow. 

Results  of  Abdominal  and  Yaginal  Examinations. — Abdominal  pal- 
pation and  vaginal  examination  both  afford  characteristic  indications 
in  well-marked  cases.  If  the  child,  as  often  happens,  has  escaped 
entirely,  or  in  great  part,  into  the  abdominal  cavity,  it  may  be  readily 
felt  through  the  abdominal  walls  ;  while  in  the  former  case,  the  par- 
tially contracted  uterus  may  bo  found  separate  from  it  in  the  form 
of  a  globular  tumor,  resembling  the  uterus  after  delivery.  Per 
vaginam  it  may  generally  be  ascertained  that  the  presenting  part 
has  suddenly  receded,  and  can  no  longer  be  made  out ;  or  some  other 
part  of  the  foetus  may  be  found  in  its  place.  If  the  rupture  be  ex- 
tensive, it  may  be  appreciable  on  vaginal  examination,  and,  some- 
times, a  loop  of  intestine  may  be  found  protruding  through  the  tear. 
Other  occasional  signs  have  been  recorded,  such  as  an  emphysema- 

1  Op.  cit.,  p.  38. 


430  LABOR. 

tous  state  of  the  lower  part  of  the  abdomen,  resulting  from  the 
entrance  of  air  into  the  cellular  tissue;  or  the  formation  of  a  san- 
guineous tumor  in  the  hypogastrium,  or  vagina.  These  are  too  un- 
common, and  too  vague,  to  be  of  much  diagnostic  value. 

Syviptoms  are  somewhat  Obscure. — Unfortunately  the  symptoms 
are  by  no  means  always  so  distinct,  and  cases  occur  in  which  most 
of  the  reliable  indications,  such  as  the  sudden  cessation  of  the  pains, 
the  external  hemorrhage,  and  the  retrocession  of  the  presenting  part, ' 
may  be  absent.  In  some  cases,  indeed,  the  symptoms  have  been  so 
obscure  that  the  real  nature  of  the  case  has  only  been  detected  after 
death.  It  is  rarely,  however,  that  the  occurrence  of  shock  and  pros- 
tration is  not  sufficiently  distinct  to  arouse  suspicion,  even  in  the 
absence  of  the  usual  marked  signs.  In  not  a  few  cases  distinct  and 
regular  contractions  have  gone  on  after  laceration,  and  the  child  has 
even  been  born  in  the  usual  way.  Of  course,  in  such  a  case,  mistake 
is  very  possible.  So  curious  a  circumstance  is  difficult  of  explana- 
tion. The  most  probable  way  of  accounting  for  it  is,  that  the  lacera- 
tion has  not  implicated  the  fundus  of  the  uterus,  which  contracted 
sufficiently  energetically  to  expel  the  foetus.  Hence  it  will  be  seen 
that  the  symptoms  are  occasionally  obscure,  and  the  practitioner 
must  be  careful  not  to  overlook  the  occurrence  of  so  serious  an 
accident,  because  of  the  absence  of  the  usual  and  characteristic 
symptoms. 

Prognosis. — The  prognosis  is  necessarily  of  the  gravest  possible 
character,  but  modern  views  as  to  treatment  perhaps  justify  us  in 
saying  that  it  is  not  so  absolutely  hopeless  as  has  been  generally 
taught  in  our  obstetric  works.  When  we  reflect  on  what  has  oc- 
curred— the  profound  nervous  shock  ;  the  profuse  hemorrhage,  both 
external,  and  especially  into  the  peritoneal  cavity,  where  the  blood 
coagulates  and  forms  a  foreign  body ;  the  passage  of  the  uterine 
contents  into  the  abdomen,  with  the  inevitable  result  of  inflamma- 
tion and  its  consequences,  if  the  patient  survive  the  primary  shock  ; 
— the  enormous  fatality  need  cause  no  surprise.  Jolly  has  found 
that  out  of  580  cases  100  recovered,  that  is,  in  the  proportion  of  1 
out  of  6.  This  is  a  far  more  favorable  result  than  we  are  generally  led 
to  anticipate  ;  and  as  many  of  the  recoveries  happened  in  apparently 
the  most  desperate  and  unfavorable  cases,  we  should  learn  the 
lesson  that  we  need  not  abandon  all  hope,  and  should  at  least  en- 
deavor to  rescue  the  patient  from  the  terrible  dangers  to  which  she 
is  exposed. 

As  regards  the  child  the  prognosis  is  almost  necessarily  fatal  ;  and 
indeed,  the  cessation  of  the  foetal  heart-sounds  has  been  pointed  out 
by  McClintock  as  a  sign  of  rupture  in  doubtful  cases.  The  shock, 
the  profuse  hemorrhage,  and  the  time  that  must  necessarily  elapse 
before  the  delivery  of  the  child,  are  of  themselves  quite  sufficient  to 
explain  the  fact  that  the  foetus  is  almost  always  dead. 

Treatrnent.-^^vom  what  has  been  said  of  the  irtipossibility  of  fore- 
telling the  occurrence  of  rupture,  it  must  follow  that  no  reliable  pro- 
phylactic treatment  can  be  adopted,  beyond  that  which  is  a  matter 
of  general  obstetric   principle,  viz.,  timely    interference   when   the 


RUPTURE  OF  THE  UTERUS.  431 

uterine  contractions  seem  incapable  of  overcoming  an  obstacle  to 
delivery,  cither  on  the  part  of  the  pelvis  or  footus. 

Indications  after  llapiure  has  taken  place. — Alter  rupture  the  main 
indications  are  to  effect  the  removal  of  the  child  and  the  placenta, 
to  rally  the  patient  from  the  effects  of  the  shock,  and,  if  she  survives 
so  lono-,  to  combat  the  subsequent  inflammation  and  its  consequences. 
By  far" the  most  important  point  to  decide  is  the  best  means  to  be 
adopted  for  the  removal  of  the  child  ;  for  it  is  admitted  by  all  that 
the  hopeless  expectancy  that  was  recommended  by  the  older  accou- 
cheurs, or,  in  other  words,  allowing  the  patient  to  die  without  making 
any  effort  to  save  her,  is  quite  inadmissible.  If  the  foetus  be  entirely 
within  the  uterine  cavity,  no  doubt  the  proper  course  to  pursue  is  to 
deliver  at  once  per  vias  naturales^  either  by  turning,  by  forceps,  or 
by  cephalotripsy.  If  any  part  other  than  the  head  present  turning 
will  be  best,  great  care  being  taken  to  avoid  further  increase  of  the 
laceration.  If  the  head  be  in  the  cavity  or  at  the  brim  of  the  pelvis, 
and  within  easy  reach  of  the  forceps,  it  may  be  cautiously  applied, 
the  child  being  steadied  by  abdominal  pressure,  so  as  to  facilitate  its 
application.  If  there  be,  as  is  often  the  case,  some  slight  amount  of 
pelvic  contraction,  it  may  be  preferable  to  perforate  and  apply  the 
cephalotribe,  so  as  to  avoid  any  forcible  attempts  at  extraction,  which 
might  unduly  exhaust  the  already  prostrate  patient,  and  turn  the 
scale  against  her.  This  will  be  the  more  allowable  since  the  child 
is,  as  we  have  seen,  almost  always  dead,  and  we  might  readily  ascer- 
tain if  it  be  so  by  auscultation. 

Removal  of  the  Placenta. — After  delivery  extreme  care  must  be 
taken  in  removing  the  placenta,  and  for  this  it  will  be  necessary  to 
introduce  the  hand.  The  placenta  will  generally  be  in  the  uterus, 
for  if  the  rent  be  not  large  enough  for  the  child  to  pass  through,  it 
may  be  inferred  that  the  placenta  will  not  have  done  so  either.  If 
it  has  escaped  from  the  uterus,  very  gentle  traction  on  the  cord  may 
bring  it  within  reach  of  the  hand,  and  so  the  passage  of  the  hand 
through  the  tear  to  search  for  it  wall  be  avoided. 

Treatment  when  the  Foetus  has  Escaped  out  of  the  Uterus. — There 
can  be  but  little  doubt  that,  in  the  cases  indicated,  such  is  the  proper 
treatment,  and  that  which  affords  the  mother  the  best  chance.  Un- 
fortunately, the  cases  in  Avhich  the  child  remains  entirely  in  utero 
are  comparatively  uncommon,  and  generally  it  will  have  escaped 
into  the  abdomen,  along  with  much  extravasated  blood.  The  visual 
plan  of  treatment  recommended,  under  such  circumstances,  is  to  pass 
the  hand  through  the  fissure  (some  have  even  recommended  that  it 
should  be  enlarged  by  incision  if  necessary),  to  seize  the  feet  of  the 
foetus,  to  drag  it  back  through  the  torn  uterus,  and  then  to  reintro- 
duce the  hand  to  search  for  and  remove  the  placenta.  Imagine  what 
occurs  during  the  process.  The  hand  gropes  blindly  among  the  ab- 
dominal viscera,  the  forcible  dragging  back  of  the  foetus  necessarily 
tears  the  uterus  more  and  more,  and,  above  all,  the  extravasated 
blood  remains  as  a  foreign  body  in  the  peritoneal  cavity,  and  neces- 
sarily gives  rise  to  the  most  serious  consequences.    It  is  surely  hardly 


432 


LABOR. 


a  matter  of  surprise  tliat  tliere  is  scarcely  a  single  case  on  record  of 
recovery  after  this  procedure. 

JReasons  favoring  G astroiomy . — Of  late  years  a  strong  feeling  lias 
existed  that,  whenever  the  cliild  has  entirely,  or  in  great  part,  escaped 
into  tlie  abdominal  cavity,  the  operation  of  gastrotomy  affords  the 
mother  a  far  better  chance  of  recovery ;  and  it  has  now  been  per- 
formed in  many  cases  with  the  most  encouraging  results.  It  is  easy 
to  see  why  the  prospects  of  success  are  greater.  The  nterus  being 
already  torn,  and  the  peritoneum  opened,  the  only  additional  danger 
is  the  incision  of  tire  abdominal  parietes,  which  gives  us  the  oppor- 
tunity of  sponging  out  the  peritoneal  cavity,  as  in  ovariotomy,  and 
of  removing  all  the  extravasated  blood,  the  retention  of  which  so 
seriously  adds  to  the  dangers  of  the  case.  Another  advantage  is 
that,  if  the  patient  be  excessively  prostrate,  the  operation  may  be 
delayed  until  she  has  somewhat  rallied  from  the  effects  of  the  shock, 
whereas  delivery  by  the  feet  is  generally  resorted  to  as  soon  as  the 
rupture  is  recognized,  and  when  the  patient  is  in  the  worst  jiossible 
condition  for  interference  of  any  kind.^ 

Comparative  Results  of  Various  Metliods  of  Treatonent. — Jolly  has 
carefully  tabulated  the  results  of  the  various  methods  of  treatment, 
and,  making  every  allowance  for  the  unavoidable  errors  of  statistics, 
it  seems  beyond  all  question  that  the  results  of  gastrotomy  are  so 
greatly  superior  to  those  of  other  plans,  that  I  think  its  adoption 
may  fairly  be  laid  down  as  a  rule  whenever  the  foetus  is  no  longer 
within  the  uterine  cavity. 

Comparative  Results  of  Various  Methods  of  Treatjiejtt  after  Rupture  of  Uterus. 


Treatment. 

No.  of  cases 

Deaths. 

Recoveries. 

Per  cent,  of 
recoveries. 

Expectation       ..... 
Exti'action  jjer  vias  naturales 
Gastrotomy 

144 

382 

38 

142 

310 

12 

2 
72 
2G 

1.45 
19 
68.4 

Of  course  this  table  will  not  justify  the  conclusion  that  68  per 
cent,  of  the  cases  of  ruptured  nterus  in  which  gastrotomy  is  per- 
formed will  recover ;  but  it  may  fairly  be  taken  as  proving  that  the 
chances  of  recovery  are  at  least  three  or  four  times  as  great  as  when 
the  more  usual  practice  is  adopted. 

[According  to  Dr.  Trask's  report^  of  cases  of  rupture  of  the  uterus, 
27  women  recovered  out  of  115  that  were  not  delivered,  and  77  out 
of  207  delivered ;  29  operations  by  laparotomy  saved  22  women. 

\_Ainerican  Puerperal  Laparotomies . — After  a  search  of  several  j^ears, 


['  I  am  fully  of  the  opinion  that  we  ought  to  go  mncli  farther  than  this,  and  ope- 
rate in  cases  even  where  the  child  can  be  readily  delivered  per  vias  naturales,  if  there 
is  a  decided  rupture  with  escape  of  blood  and  liquor  amnii  into  the  abdominal  cavity, 
for  the  removal  of  these  fluids  is  only  second  in  importance  to  that  of  the  foetus.  In 
cervico-vaginal  rupture  this  is  not  so  important,  as  there  is  generally  a  natural  drain- 
age ;  but  where  the  body  or  fundus  have  been  freely  rent,  there  is  no  security  equal 
to  that  of  opening  the  abdomen  and  cleaning  it  out. — Ed.] 

[2  Am.  Journ.  Med.  Sci.,  vol.  xv.  N.  S.  1848,  pp.  104,  383;  vol.  xxxii.  p.  81.] 


RUPTURE  OF  THE  UTERUS.  433 

I  have  thus  far  collected  40  cases*  in  the  United  States,  with  21 
women  and  2  children  saved.  One  mother  and  child  were  saved  by 
an  immediate  operation  with  a  pocket-knife,  in  1869,  I  presume 
that  a  general  record  of  American  operations  published  and  unpub- 
lished would  show  a  saving  of  about  50  per  cent.,  which  is  much 
lower  than  that  claimed  by  Trask  and  JoWy,  collected  from  published 
reports,  and  less  than  I  thought  myself  a  year  ago.  Take  Trask's 
foreign  cases,  20,  and  our  own  40,  and  we  have,  native  and  foreign, 
60,  with  37  recoveries  and  23  deaths.  I  look  upon  our  own  statistics 
as  much  more  reliable,  because  many  of  the  unpublished  cases  were 
searched  out  by  correspondence.- — ^Ed.] 

Necessity  of  Care  in  Performimj  the  Operation. — It  is  perhaps  need- 
less to  say  that  the  operation  must  be  performed  with  the  same 
minute  care  that  has  raised  ovariotomy  to  its  present  pitch  of  per- 
fection, and  that  especial  attention  should  be  paid  to  the  sponging 
out  of  the  peritoneum,  and  the  removal  of  foreign  matters. 

Recapitulation. — To  recapitulate,  I  think  what  has  been  said  jus- 
tifies the  following  rules  of  treatment  after  rupture : — 

1.  If  the  head  or  presenting  part  be  above  the  brim,  and  the  foetus 
still  in  utero — forceps,  turning,  or  cephalotripsy,  according  to  circum- 
stances. 

2.  If  the  head  be  in  the  pelvic  cavity — forceps  or  cephalotripsv. 

3.  If  the  foetus  have  wholly,  or  in  great  part,  escajDed  into  the 
abdominal  cavity — gastrotomy. 

[I  know  that  these  rules  are  those  which  have  been  given  in  ob- 
stetrical works  of  high  authority,  but  still  I  believe  them  to  be  based 
upon  the  errors  of  the  past,  and  the  cause  of  a  high  degree  of  mor- 
tality. Let  any  one  examine  Dr.  Trask's  tables,  and  he  will  learn 
how  few  are  likely  to  be  saved  under  these  rules.  Children  entirely 
escaped  into  the  abdominal  cavity  have  been  drawn  back  into  the 
uterus  and  the  women  have  recovered.  So  also  of  the  same  condi- 
tions, where  the  foetus  has  been  left  intact.  But  we  are  not  to  ex- 
pect such  results.  What  we  are  to  look  for  is  death  in  frightful 
proportion  under  any  of  these  rules.  I  do  not  object  to  the  manner 
of  delivery,  but  I  do  to  the  closing  of  the  case  here.  In  all  cases 
where  the  state  of  the  woman  will  warrant  it,  I  believe  that  the 
abdomen  should  be  opened  and  sponged  out,  and  wd:iere  the  uterine 
wound  gapes,  that  it  should  be  closed  by  sutures.- — Ed.] 

Subsequent  Treatment. — As  to  the  subsequent  treatment  little  need 
be  said,  since  in  this  we  must  be  guided  by  general  principles.  The 
chief  indication  will  be  to  remove  shock  and  rally  the  patient  by 
stimulants,  etc.,  and  to  combat  secondary  results  by  opiates  and  other 
appropriate  remedies. 

Lacerations  of  the  vagina  occasionally  take  place,  and  in  the  great 
majority  of  cases,  they  are  produced  by  instruments,  either  from  a 
want  of  care  in  their  introduction,  or  from  undue  stretching  of  the 
vaginal  walls  during  extraction  with  the  forceps.  Slight  vaginal 
lacerations  are  probably  much  more  common  after  forceps  delivery 
than  is  generally  believed  to  be  the  case.  As  a  rule,  they  are  pro- 
ductive of  no  permanent  injury,  although  it  must  not  be  forgotten 


434  LABOR. 

that  every  breach  of  continuity  increases  the  risk  of  subsequent 
septic  absorption.  When  the  laceration  is  sufficiently  deep  to  tear 
through  the  recto- vaginal  septum,  or  the  anterior  vaginal  wall,  the 
passage  of  the  urine  or  feces  is  apt  to  prevent  its  edges  uniting;  then 
that  most  distressing  condition,  recto-vaginal,  or  vesico- vaginal  fistula 
is  established. 

It  must  not  be  supposed  that  fistula?  are  often  the  result  of  injury 
during  operative  interference.  That  is  a  common  but  very  erroneous 
opinion  both  among  the  profession  and  the  public.  In  the  vast 
majority  of  cases  the  fistulous  opening  is  the  consequence  of  a  slough 
resulting  from  inflammation,  produced  by  long-continued  pressure  of 
the  vaginal  walls  between  the  child's  head  and  the  bony  pelvis,  in 
cases  in  which  the  second  stage  has  been  allowed  to  go  on  too  long. 
In  most  of  these  cases  instruments  were  doubtless  eventually  used, 
and  they  get  the  blame  of  the  accident ;  whereas  the  fault  lay,  not 
in  their  being  employed,  but  rather  in  their  not  having  been  used 
soon  enough  to  prevent  the  contusion  and  inflammation  which  ended 
in  sloughing. 

When  vesico-vaginal  fistulse  are  the  result  of  lacerations  during 
labor,  the  urine  must  escape  at  once,  but  this  is  rarely  the  case.  In 
the  large  majority  of  cases  the  urine  does  not  pass  per  vaginam  until 
more  than  a  week  after  delivery,  showing  that  a  lapse  of  time  is 
necessary  for  inflammatory  action  to  lead  to  sloughing.  In  order  to 
throw  some  light  on  these  points,  on  which  very  erroneous  views 
have  been  held,  I  have  carefully  examined  the  histories,  from  various 
sources,  of  63  cases  of  vesico-vaginal  fistula. 

1st.  In  20  no  instruments  were  employed.     Of  these,  there  were 
in  labor  under  24  hours        .....         2 
from  24  to  48  hours 

"    48  to  70      "  .         . 

"    70  to  80      "  .         . 

''     80  hours  and  upwards    . 


8^ 
2 
7 
1 


20 

Therefore  out  of  these  20  cases  one-half  were  certainly  more  than 
48  hours  in  labor,  and  6  of  the  remaining  10  were  probably  so  also. 
In  only  1  of  them  is  the  urine  stated  to  have  escaped  per  vaginam 
immediately  after  delivery.     In  7  it  is  said  to  have  done  so  within 
a  week,  and  in  the  remainder  after  the  seventh  day. 

2d.  In  34  cases  instruments  were  used,  but  there  is  no  evidence  of 
their  having  produced  the  accident.     Of  these,  there  were  in  labor 
under  24  hours    .          .         .         .          .         ...         2 

from  24  to  48  hours        ...         8 
"    48  to  72         "  .         .       10 

"     72  hours  and  upwards    .         •       14 

34 

1  But  of  these  in  7  no  precise  time  is  stated.     6  of  tliem  are  marked  very  tedious, 
therefore  they  probably  exceeded  the  limit. 


INVERSION  OF  THE  UTERUS.  435 

The  urine  escaped  within  24:  hours  in  2  cases  only,  within  a  week  in 
16^  and  after  the  seventh  day  in  15. 

So  that  here  again  we  have  the  history  of  unduly  protracted 
delivery,  24  out  of  the  34  having  been  certainly  more  than  48  hours 
in  labor. 

3d.  In  -9  cases  the  histories  show  that  the  production  of  the  fistula 
may  fairly  be  ascribed  to  the  unslcilled  use  of  instruments.    Of  these 
there  were  in  labor  under  24  hours     ...         7 
from  24  to  48  hours        ...         1 
"    48  to  72      "  .         .         .         1 

9 

The  urine  escaped  at  once  in  7  cases,  and  in  the  remaining  2  after 
the  seventh  day. 

These  statistics  seem  to  me  to  prove,  in  the  clearest  manner,  that, 
in  the  large  majority  of  cases,  this  unhap])y  accident  may  be  directly 
traced  to  the  bad  practice  of  allowing  labor  to  drag  on  many  hours 
in  the  second  stage  without  assistance,  and  not  to  premature  instru- 
mental interference.  This  question  has  recently  been  elaborately 
studied  by  Emmet,  who  gives  numerous  statistical  tables  which  fully 
corroborate  these  views.  His  conclusion,  the  result  of  much  prac- 
tical experience  of  vesico- vaginal  fistulte,  is  worthy  of  being  quoted: 
"  I  do  not  hesitate,"  he  says,  "  to  make  the  statement  that  I  have 
never  met  with  a  case  of  vesico- vaginal  fistula  which,  without  doubt, 
could  be  shown  to  have  resulted  from  instrumental  delivery.  On 
the  contrary,  the  entire  weight  of  evidence  is  conclusive  in  showing 
that  the  injury  is  a  consequence  of  delay  in  delivery."^ 

Treatment. — As  to  the  treatment  of  vaginal  laceration  little  can 
be  said.  In  the  slighter  cases  vaginal  injections  of  diluted  Condy's 
fluid  will  be  useful  to  lessen  the  risk  of  septic  absorption ;  and  the 
graver,  when  vesico-vaginal  or  recto- vaginal  fistulse  have  actually 
formed,  are  not  within  the  domain  of  the  obstetrician,  but  must  be 
treated  surgically  at  some  future  date. 


CHAPTEE    XYII. 

INVERSION  OF  THE  UTERUS. 

Inversion  of  the  uterus  shortly  after  the  birth  of  the  child  is  one 
of  the  most  formidable  accidents  of  parturition,  leading  to  symptoms 
of  the  greatest  urgency,  not  rarely  proving  fatal,  and  requiring  prompt 
and  skilful  treatment.     Hence  it  has  obtained  an  unusual  amount  of 

'  The  Principles  and  Practice  of  Gynaecology,  p.  669. 


436 


LABOR. 


Fig.  140. 


attention,  and  there  are  few  obstetric  subjects  which,  have  been  more 
carefully  studied. 

An  Accident  of  Great  Rarity. — -Fortunately,  the  accident  is  of  great 
rarity.  It  was  only  observed  once  in  upwards  of  190,800  deliveries 
at  the  Eotunda  Hospital  since  its  foundation  in.  1745  ;  and  many 
practitioners  have  conducted  large  midwifery  practices  for  a  lifetime 
without  ever  having  witnessed  a  case.  It  is  none  the  less  needful, 
howeve:',  that  we  should  be  thoroughly  acquainted  with  its  natural 
history,  and  with  the  best  means  of  dealing  with  the  emergency  when 
it  arises. 

Division  into  Acute  and  Chronic  Forms.- — Inversion  of  the  uterus 
may  be  met  with  in  the  acute  or  chronic  form  ;  that  is  to  say,  it  may 
come  under  observation  either  immediately  or  shortly  after  its  occur- 
rence, or  not  until  after  a  considerable  lapse  of  time,  when  the  invo- 
lution following  pregnancy  has  been  completed.  The  latter  falls 
more  properly  under  the  province  of  the  gynecologist,  and  involves 
the  consideration  of  many  points  that  would  be.  out  of  place  in  a 
work  on  obstetrics.  Here,  therefore,  the  acute  form  alone  is  con- 
sidered. 

Descri'ption  of  Inversion. — Inversion  consists  essentially  in  the  en- 
larged and  empty  uterus  being  turned  inside  out,  either  partially  or 

entirely  ;  and  this  may  occur  in  various 
degrees,  three  of  which  are  usually  de- 
scribed, and  are  practically  useful  to 
bear  in  mind.  In  the  first  and  slightest 
degree  there  is  merely  a  cup-shaped 
depression  of  the  fundus  (Fig.  140); 
in  the  second  the  depression  is  greater, 
so  that  the  inverted  portion  forms  an 
introsusception,  as  it  were,  and  projects 
downwards  through  the  os  in  the  form 
of  a  round  ball,  not  unlike  the  body  of 
a  polypus,  for  which,  indeed,  a  careless 
observer  might  mistake  it;  and,  thirdly, 
there  is  the  complete  variety,  in  which 
the  whole  organ  is  turned  inside  out 
and  may  even  project  beyond  the  vulva. 
Its  Syrnj^toms. — The  symptoms  are 
generally  very  characteristic,  although, 
when  the  amount  of  inversion  is  small, 
they  may  entirely  escape  observation. 
They  are  chiefly  those  of  profound  ner- 
vous shock,  viz.,  fainting,  small,  rapid, 
and  feeble  pulse,  possibly''  convulsions 
and  vomiting,  and  a  cold,  clammy  skin.  Occasionally  severe  ab- 
dominal pain,  and  cramp  and  bearing  down  are  felt.  Hemorrhage 
is  a  frequent  accompaniment,  sometimes  to  a  very  alarming  extent, 
especially  if  the  placenta  be  partially  or  entirely  detached.  The  loss 
of  blood  depends  to  a  great  extent  on  the  condition  of  the  uterine 
parietes.      If  there  be  much  contraction  of  the  part  that  is  not  in- 


Partial  Inversion  of  the  Fundus. 
(From  a  preparation  in  the  museum  of 
Guy's  Hospital.) 


INVERSION  OF  THE  UTERUS.  43T 

verted,  the  introsusceptcd  part  may  be  sufficiently  compressed  to  pre- 
vent any  great  loss.  If  the  entire  organ  be  in  a  state  of  relaxation, 
the  loss  may  be  excessive. 

ResidLs  of  Physical  Examination. — The  occurrence  of  such  symp- 
toms shortly  after  delivery  would  of  necessity  lead  to  an  accurate 
examination,  when  the  nature  of  the  case  may  be  at  once  ascertained. 
On  passing  the  linger  into  the  vagina,  we  either  find  the  entire  uterus 
forming  a  globular  mass,  to  which  the  placenta  is  often  attached  ; 
or,  if  the  inversion  be  incomplete,  the  vagina  is  occupied  by  a  firm, 
round,  and  tender  swelling,  which  can  be  traced  upwards  tlirough  the 
OS  uteri.  The  hand  placed  on  the  abdomen  will  detect  the  absence 
of  the  round  ball  of  the  contracted  uterus,  and  bi-manual  examina- 
tion may  even  enable  us  to  to  feel  the  cup-shaped  depression  at  the 
site  of  inversion. 

Differential  Diagnosis. — When  such  signs  arc  observed  immedi- 
ately after  delivery,  mistake  is  hardly  possible.  JSTumerous  instances, 
however,  are  recorded  in  which  the  existence  of  inversion  was  not 
immediately  detected,  and  the  tumor  formed,  by  it  only  observed 
after  the  lapse  of  several  days,  or  even  longer,  when  the  general 
symptoms  led  to  vaginal  examination.  It  is  probable  that,  in  such 
cases,  a  partial  inversion  had  taken  place  shortly  after  delivery, 
which,  as  time  elapsed,  became  gradually  converted  into  the  more 
complete  variety.  In  a  case  of  this  kind,  as  in  a' chronic  inversion, 
some  care  is  necessary  to  distinguish  the  inversion  from  a  uterine 
polypus,  which  it  closely  resembles.  The  cautious  insertion  of  the 
sound  will  render  the  diagnosis  certain,  since  its  passage  is  soon  ar- 
rested in  inversion,  while,  if  the  tumor  be  polypoid,  it  readily  passes 
in  as  far  as  the  fundus. 

Manner  in  which  Inversion  is  Produced. — Tb.e  mechanism  by  which 
inversion  is  produced  is  well  worthy  of  study,  and  has  given  rise  to 
much  difference  of  opinion. 

Occasionally  produced  hy  Accidental  Mechanical  Causes. — A  very 
general  theory  is,  that  it  is  caused,  in  many  cases,  by  mismanage- 
ment of  the  third  stage  of  labor,  either  by  traction  on  the  cord,  the 
placenta  being  still  adherent,  or  by  improperly  applied  pressure  on 
the  fundus  ;  the  result  of  both  these  errors  being  a  cup-shaped  de- 
pression of  the  fundus,  which  is  subsequently  converted  into  a  more 
complete  variety  of  inversion.  That  such  causes  may  suffice  to  start 
the  inversion  cannot  be  doubted,  but  it  is  probable  that  their  fre- 
quency has  been  much  exaggerated.  Still  there  are  numerous  re- 
corded cases  in  which  the  commencement  of  the  inversion  can  be 
traced  to  them.  Improperly  applied  pressure  (as  when  the  whole 
body  of  the  uterus  is  not  grasped  in  the  hollow  of  the  hand,  but 
when  a  monthly  nurse,  or  other  uninstructed  person,  presses  on  the 
lower  part  of  the  abdomen,  so  as  simply  to  push  down  the  uterus  en 
masse)  is  often  mentioned  in  histories  of  the  accident.  Thiis  in  the 
"  Edinburgh  Medical  Journal"  for  June,  1848,  a  case  is  related  in 
which  the  patient  would  not  have  a  medical  man,  but  was  attended 
by  a  midwife,  who,  after  the  birth  of  the  child,  pulled  on  the  cord, 
while  the  patient  herself  clasped  her  hands  and  pushed  down  her 


433  LABOR. 

abdomen,  at  the  same  time  straining  forcibly,  when  tlie  uterus  be- 
came inverted  and  the  patient  died  of  hemorrhage  before  assistance 
could  be  procured.  Here  both  of  the  mechanical  causes  mentioned 
were  in  operation.  In  several  cases  it  is  mentioned  that  the  accident 
occurred  Avhile  the  nurse  was  compressing  the  abdomen.  That  the 
accident  is  practically  impossible  when  firm  and  equable  contraction 
has  taken  place,  cannot  be  questioned.  Hence  it  is  of  paramount 
huportance  that  the  practitioner  should  himself  carefully  attend  to 
the  conduct  of  the  third  stage  of  labor. 

Often  Occurs  Spontaneously.- — In  a  large  proportion  of  cases  no 
mechanical  causes  can  be  traced,  and  the  occurrence  of  spontaneous 
inversion  must  be  admitted.  There  are  various  theories  held  as  to 
how  this  occurs.  Partial  and  irregular  contraction  of  the  uterus  is 
generally  admitted  to  be  an  important  factor  in  its  production :  but 
it  is  still  a  matter  of  dispute  whether  the  inversion  is  produced  mainly 
by  an  active  contraction  of  the  fundus  and  body  of  the  uterus,  the 
lower  portion  and  cervix  being  in  a  state  of  relaxation ;  or  wliether 
the  precise  reverse  of  this  exists,  the  fundus  being  relaxed  and  in  a 
state  of  quasi-paralysis,  while  the  cervix  and  lower  portion  of  the 
uterus  are  irregularly  contracted.  The  former  is  the  view  main- 
tained by  Eadford  and  Tyler  Smith,  while  the  latter  is  upheld  by 
Matthews  Duncan. 

Evidence  in  Favor  of  Duncan^ s  Theory. — There  are  good  clinical 
reasons  for  believing  that  Duncan's  view  more  nearly  corresponds 
with  the  true  facts  of  the  case  ;  for,  if  the  fundus  ancl  body  of  the 
uterus  be  really  in  a  state  of  active  contraction,  while  the  cervix  is 
relaxed,  we  have,  as  Duncan  points  out,  the  very  condition  which  is 
normal  and  desirable  after  delivery,  and  that  which  we  do  our  best 
to  produce.  If,  however,  the  opposite  condition  exist,  and  the  fundus 
be  relaxed,  while  the  lower  portion  is  spasmodically  contracted,  a 
state  exists  closely  allied  to  the  so-called  hour-glass  contraction. 
Supposing  now  any  cause  produces  a  partial  depression  of  the  fundus, 
it  is  easy  to  understand  how  it  may  be  grasped  by  the  contracted 
portion,  and  carried  more  and  more  clown,  in  the  manner  of  an  intro- 
susception,  until  complete  inversion  results.  That  such  partial  paraly- 
sis of  the  uterine  walls  often  exists,  especially  about  the  placental 
site  was  long  ago  pointed  out  by  Rokitansky,  and  other  pathologists. 
This  theory  supposes  the  original  partial  depression  and  relaxation 
of  the  fundus.  How  this  is  often  produced  by  mismanagement  of 
the  third  stage  has  already  been  pointed  out;  but,  even  in  the  absence 
of  such  causes,  it  may  result  from  strong  bearing-down  efforts  on  the 
part  of  the  patient,  or,  as  Duncan  holds,  from  the  absence  of  the 
retentive  power  of  the  abdomen.  Indeed  the  incompatibility  of  an 
actively  contracted  state  of  the  fundus  with  the  partial  depression 
which  is  essential,  according  to  both  views,  for  the  production  of 
inversion,  is  the  strongest  argument  in  favor  of  Duncan's  theor3^ 

Taylor^s  Theory. — A  totally  difterent  view  has  more  recently  been 
sustained  by  Dr.  Taylor,  of  New  York,  who  maintains  that  "  spon- 
taneous active  inversion  of  the  uterus  rests  upon  prolonged  natural 
and  energetic  action  of  the  body  and  fundus ;  the  cervix,  the  lower 


INVERSION    OF    THE    UTERUS. 


439 


Fig.  141. 


part,  yielding  first,  is  thus  rolled  oiit,  or  everted,  or  doubled  up,  as 
there  is  no  obstruction  from  the  contractility  of  the  cervix,  which  is 
at  rest  or  functionally  paralyzed ;  the  body  is  gradually,  sometimes 
instantaneously,  forced  lower  and  lower,  or  inveited.''^  That  partial 
inversion  may  commence  at  the  cervix  was  pointed  out  by  Duncan 
in  his  paper,  who  depicts  it  in  the  accompanying  diagram  (Fig.  141), 
and  states  it  to  be  of  not  unfrequent  occurrence.  It  is  not  impossible 
that  occasionally  such  a  state  of  things  should  be  carried  on  to  com- 
plete inversion.  But  there  are  serious  ob- 
jections to  the  acceptance  of  Dr.  Taylor's- 
view  that  such  is  the  principal  cause  of 
inversion,  since  the  process  above  described 
would  be  of  necessity  a  slow  and  long- 
continued  one,  whereas  nothing  is  more  cer- 
tain than  that  inversion  is  generally  sudden 
and  accompanied  by  acute  symptoms  of 
shock,  and  is  often  attended  by  severe  hem- 
orrhage, which  could  not  occur  when  such 
excessive  contraction  was  taking  place. 

Treatment. — The  treatment  of  inversion 
consists  in  restoring  the  organ  to  its  natural 
condition  as  soon  as  possible.  Every 
moment's  delay  only  serves  to  render  res- 
toration more  difficult,  as  the  inverted  por- 
tion becomes  swollen  and  strangulated ; 
whereas  if  the  attempt  at  reposition  be 
made  immediately,  there  is  generally  com- 
])aratively  little  difficult}^  in  effecting  it. 
Therefore  it  is  of  the  utmost  importance  that 
no  time  should  be  lost,  and  that  we  should  not  overlook  a  partial  or 
incomplete  inversion.  Hence  the  occurrence  of  any  unusual  shock, 
pain,  or  hemorrhage  after  delivery,  without  any  readily  ascertained 
cause,  should  always  lead  to  a  careful  vaginal  examination.  A  want 
of  attention  to  this  rule  has  too  often  resulted  in  the  existence  ol 
partial  inversion  being  overlooked,  until  its  reduction  was  found  to 
be  difficult  or  impossible. 

Mode  of  Attempting  Reduction. — In  attempting  to  reduce  a  recent 
inversion,  the  inverted  portion  of  the  uterus  should  be  grasped  in 
the  hollow  of  the  hand  and  pushed  gently  and  firmly  upwards  into 
its  natural  position,  great  care  being  taken  to  apply  the  pressure  in 
the  proper  axis  of  the  pelvis,  and  to  use  counter-pressure,  by  the 
left  hand,  on  the  abdominal  walls.  Barnes  lays  stress  on  the  import- 
ance of  directing  the  pressure  towards  one  side,  so  as  to  avoid,  the 
promontory  of  the  sacrum.  The  common  plan  of  endeavoring  to 
push  back  the  fundus  first  has  been  well  shown  by  McClintock^  to 
have  the  disadvantage  of  increasing  the  bulk  of  the  mass  that  has 
to  be  reduced,  and  he  advises  that,  while  the  fundus  is  lessened  in 
size  by  compression,  we  should,  at  the  same  time,  endeavor  to  push 


lUustratinor  the  Commencemeiit 
of  laversioa  at  the  Cervix.  (After 
Duncan.) 


1  New  York  Med.  Journ.,  1872. 


2  Diseases  of  Women,  p.  79. 


440  LABOR. 

up  first  the  part  that  was  less  inverted,  tliat  is  to  saj,  the  portion 
nearest  the  os  uteri.  Should  this  be  found  impossible,  some  assist- 
ance may  be  derived  from  the  manoeuvre,  recommended  by  Merriman 
and  others,  of  first  endeavoring  to  push  up  one  side  or  wall  of  the 
uterus,  and  then  the  other,  alternating  the  iipward  pressure  from  one 
side  to  the  other  as  we  advance.  It  often  happens  as  the  hand  is 
thus  applied,  that  the  uterus  somewhat  suddenlj^  reinverts  itself, 
sometimes  with  an  audible  noise,  much  as  an  India-rubber  bottle 
would  do  under  similar  circumstances.  When  reposition  has  taken 
place  the  hand  should  be  kept  for  some  time  in  the  uterine  cavity  to 
excite  tonic  contraction  ;  or  Barnes's  suggestion  of  injecting  a  weak 
solution  of  perchloride  of  iron  may  be  adopted,  so  as  to  constrict  the 
uterine  walls,  and  prevent  a  recurrence  of  the  accident. 

It  is  hardly  necessary  to  point  out  how  much  these  manoeuvres 
will  be  facilitated  by  placing  the  patient  fully  under  the  influence  of 
an  anaesthetic. 

Management  of  the  Placenta. — There  has  been  much  difference  of 
opinion  as  to  the  management  of  the  j)lacenta  in  cases  in  which  it  is 
still  attached  when  inversion  occurs.  Should  we  remove  it  before 
attempting  'reposition,  or  should  we  first  endeavor  to  reinvert  the 
organ,  and  subsequently  remove  the  placenta  ?  The  removal  of  the 
placenta  certainly  much  diminishes  the  bulk  of  the  inverted  portion, 
and,  therefore,  renders  reposition  easier.  On  the  other  hand,  if  there 
be  much  hemorrhage,  as  is  so  frequently  the  case,  the  removal  of  the 
placenta  may  materially  increase  the  loss  of  blood.  For  this  reason, 
most  authorities  recommend  that  an  endeavor  should  be  made  at 
reduction  before  peeling  off  the  after-birth.  But  if  any  delay  or 
difficulty  be  experienced  from  the  increased  bulk,  no  time  should  be 
lost,  and  it  is  in  every  way  better  to  remove  the  placenta  and  en- 
deavor to  reinvert  the  organ  as  soon  as  possible. 

Management  of  Cases  detected  some  time  after  Delivery. — Supposing 
we  meet  with  a  case  in  which  the  existence  of  inversion  has  been 
overlooked  for  days,  or  even  for  a  week  or  two,  the  same  procedure 
must  be  adopted;  but  the  difficulties  are  much  greater,  and  the 
longer  the  delay,  the  greater  they  are  likely  to  be.  Even  now, 
however,  a  well-conducted  attempt  at  taxis  is  likely  to  succeed. 
Should  it  fail,  we  must  endeavor  to  overcome  the  difficulty  by  con- 
tinuous pressure  applied  by  means  of  caoutchouc  bags,  distended 
with  water,  and  left  in  the  va,gina.  It  is  rarely  that  this  will  fail  in 
a  comparatively  recent  case,  and  such  only  are  now  under  considera- 
tion. It  is  likely  that  by  pressure,  applied  in  this  way  for  twenty- 
four  or  forty-eight  hours,  and  then  followed  by  taxis,  any  case 
detected  before  the  involution  of  the  uterus  is  completed  may  be 
successfully  treated. 

\_Spontaneous  Reposition  of  the  Inverted  Uterus. — After  all  attempts 
have  failed  to  replace  an  inverted  uterus,  already  too  much  contracted 
to  yield  to  the  pressure  employed,  nature  sometimes  accomplishes 
the  work  herself,  as  proved  beyond  question,  from  quite  a  number 
of  well-established  cases,  several  of  which  belong  to  our  own  country. 

Quite  recently  I  saw  one  of  the  most  remarkable  on  record.     A 


INVERSION  OF  THE  UTERUS.  441 

woman  of  29,  mother  of  three,  miscarried  at  six  and  a  half  months 
fiom  lifting.  From  the  time  of  her  delivery  she  was  subject  to  weep- 
ings of  blood,  and  at  times  to  more  or  less  severe  hemorrhages,  one  of 
which  a  few  weeks  ago  nearly  proved  fatal.  This  condition  of  dis- 
ease had  lasted  three  years,  when  Dr.  Walter  F.  Atlee  was  called  in 
to  relieve  her  in  her  worst  hemorrhagic  attack,  and  found  her  uterus 
inverted,  and  a  nodular  growth  upon  the  fundus  which  gave  out  an 
offensive  odor.  Thinking  the  disease  possibly  malignant,  and  be- 
lieving in  any  event,  that  to  save  the  woman  he  would  be  obliged  to 
remove  the  uterus,  he  called  a  consultation,  and  prepared  for  the 
operation ;  but  when  the  patient  was  etherized,  placed  in  the  knee- 
chest  position,  and  Sims's  speculum  introduced,  behold  there  was 
nothing  to  be  seen  in  the  vagina  but  a  soft  dilated  cervix,  the  uterus 
having  become  replaced  by  atmospheric  pressure,  aided  perhaps  by 
traction  on  the  uterine  attachments  within.  When  explored,  the 
uterus  was  found  to  be  very  soft  and  thin,  and  to  contain  some  hard 
nodular  masses,  Avhich  on  removal  proved  to  be  portions  of  an  adhe- 
rent placenta.  The  hemorrhage  ceased  upon  the  reposition  and  clean- 
ing out  of  the  uterus,  and  the  patient  made  a  good  recovery. 

This  woman  was  ana3mic  to  a  marked  degree,  and  her  abdominal 
walls  so  thin  that  a  finger  in  the  uterus  could  readily  be  felt  above 
the  pubes.  There  is  not  the  slightest  doubt  about  the  inversion, 
which  was  proved  to  exist  a  short  time  before  the  change  of  posture 
by  Dr.  Agnew,  who  made  a  finger  in  the  rectum  meet  another  above 
the  pubes,  and  there  was  no  fundus  between  them. 

Two'  cases  are  upon  record  where  reposition  was  the  result  of  falls, 
one  at  eight  months,  and  the  other  after  as  many  years.  Dr.  Moehr- 
ing,  Meigs,  Hodge,  and  Warrington  of  this  city,  failed  to  replace  a 
uterus,  and  the  woman  became  again  pregnant  in  about  six  3'ears, 
aborting  with  a  three  months'  foetus  under  the  care  of  Dr.  Warring- 
ton. Dr.  Meigs  saw  a  second  case  with  Dr.  Levis,  in  which  there 
w^as  violent  flooding  followed  by  hemorrhages  which  gradually  de- 
clined. After  her  return  from  a  journey  West,  she  became  pregnant 
and  bore  a  child.  Dr.  John  L.  Atlee,  of  Lancaster,  failed  to  replace 
a  uterus  in  a  woman  who  bore  a  child  a  year  afterwards.^  Dr.  tfohn- 
son  F.  Hatch,  of  Kent,  Connecticut,  reported  a  case  in  a  letter  to  Dr. 
Meigs,  in  which  inversion  occcurred  spontaneously,  fourteen  or  fif- 
teen hours  after  labor.  After  being  under  the  care  of  several  physi- 
cians, she  had,  at  the  end  of  eighteen  months,  two  severe  hemorrha- 
gic attacks  after  which  she  improved,  and  finally  at  the  end  of  two 
years  and  nine  months,  bore  a  child  of  9  pounds  and  6  ounces. 

In  all  cases,  spontaneous  reposition  appears  to  result  from  a  soft- 
ening and  thinning  of  the  uterine  walls,  as  the  result  of  anaemia 
brought  on  by  hemorrhages.  This  was  particularly  noticed  by 
Boivin  and  Dug^s,  in  autopsies  of  women  dying  of  repeated  hemor- 
rhages.— Ed,] 

['  See  Dailliez,  Essai  snr  le  renverfsement  de  la  matrice,  Paris,  1S05,  pp.  105-107.] 
[^  Meigs's  Obstetrics,  1852,  Pliila.  p.  608.] 
29 


PART   IT. 

OBSTETRIC   OPERATIONS. 


CHAPTER   I. 

INDUCTION   OF   PREMATUEE    LABOR. 

The  first  of  the  obstetric  operations  we  liave  to  consider  is  the 
induction  of  premature  labor,  an  operation  which,  like  the  use  of  for- 
ceps, was  first  suggested  and  practised  in  this  country,  and  the  recog- 
nition of  which,  as  a  legitimate  procedure,  we  also  chiefly  owe  to  the 
labor  of  our  fellow-countrymen,  in  spite  of  much  opposition  both  at 
home  and  abroad.  It  is  not  known  with  certainty  to  whom  we  owe 
the  original  suggestion ;  but  we  are  told  by  Denman  that  in  the  year 
1756  there  was  a  consultation  of  the  most  eminent  physicians  at  that 
time  in  London,  to  consider  the  advantages  which  might  be  expected 
from  the  operation.  The  proposal  met  with  formal  approval,  and 
was  shortly  after  carried  into  practice  by  Dr.  Macaulay,  the  patient 
being  the  wife  of  a  linendraper  in  the  Strand.  From  that  time  it 
has  flourished  in  Great  Britain,  the  sphere  of  its  application  has  been 
largely  increased,  and  it  has  been  the  means  of  saving  many  mothers 
and  children,  who  would  otherwise,  in  all  probability  have  perished. 
On  the  Continent,  it  was  long  before  the  operation  was  sanctioned  or 
practised.  Although  recommended  by  some  of  the  most  eminent 
German  practitioners,  it  was  not  actually  performed  until  the  year 
1804:.  In  France  the  opposition  was  long  continued  and  bitter. 
Many  of  the  leading  teachers  strongly  denounced  it,  and  the  Academy 
of  Medicine  formally  discountenanced  it  so  late  as  the  year  1827. 
The  objections  were  chiefly  based  on  religious  grounds,  but  partly, 
no  doubt,  on  mistaken  notions  as  to  the  object  proposed  to  be  gained. 
Although  frequently  discussed,  the  operation  Avas  never  actually  car- 
ried into  practice  until  the  year  1831,  when  Stoltz  performed  it  with 
success.  Since  that  time  opposition  has  greatly  ceased,  and  it  is  now 
employed  and  highly  recommended  by  the  most  distinguished  ob- 
stetricians of  the  French  schools. 

Objects  of  the  Operation. — In  inducing  premature  labor,  we  propose 
to  avoid  or  lessen  the  risk  to  which,  in  certain  cases,  the  mother  is 
exposed  by  delivery  at  term,  or  to  save  the  life  of  the  child  which 
might  otherwise  be  endangered.  Hence  the  operation  may  be  indi- 
cated either  on  account  of  the  mother  alone,  or  of  the  child  alone,  or, 
as  not  unfrequently  happens,  of  both  together, 
( 442  ) 


INDUCTION    OF    PREMATURE    LABOR.  443 

Defective  Proportion  hdween  the  Child  and  Pelvis  is  the  most  Fre- 
quent Indication. — In  by  far  tlic  largest  number  of  cases  the  operation 
is  performed  on  account  of  defective  proportion  between  tfie  child 
and  the  maternal  passages,  due  to  some  abnormal  condition  on  the 
part  of  the  mother.  This  want  of  proportion  may  depend  on  the 
presence  of  tumors  either  of  the  uterus  or  growing  from  tiie  pelvis. 
Bat  most  frequently  it  arises  from  deformity  of  the  pelvis  (p.  389), 
and  it  is  needless  to  repeat  what  has  been  said  on  that  point.  I 
shall,  therefore,  only  briefly  refer  to  a  few  more  uncommon  causes, 
which  occasionally  necessitate  its  performance. 

Habitually  Large  Size  of  the  Foetal  Head. — One  of  these  is  an  habit- 
ually large,  or  over-fimly  ossified,  foetal  head.  Should  we  meet 
with  a  case  in  which  the  labors  are  always  extremely  difficult,  and 
the  head  apparently  of  unusual  size,  although  there  is  no  apparent 
want  of  space  in  the  pelvis,  the  induction  of  labor  would  be  perfectly 
justifiable,  and  in  all  probability  would  accomplish  the  desired  ob- 
ject. In  such  cases  the  full  period  of  delivery  would  require  to  be 
anticipated  by  a  very  short  time.  A  week  or  a  fortnight  might 
make  all  the  difference  between  a  labor  of  extreme  severity,  and  one 
of  comparative  ease. 

Condition  of  the  Mother'' s  Health  calling  for  the  operation. — There 
is  a  large  class  of  cases  in  which  the  condition  of  the  mother  indi- 
cates the  operation.  Many  of  these  have  already  been  considered 
when  treating  of  the  diseases  of  pregnancy.  Amongst  them  may  be 
mentioned  vomiting  which  has  resisted  all  treatment,  and  which  has 
produced  a  state  of  exhaustion  threatening  to  prove  fatal ;  chorea, 
albuminuria,  convulsions,  or  mania ;  excessive  anasarca,  ascites,  or 
dyspnoea  connected  with  disease  of  the  heart,  lungs,  or  liver,  may  be, 
in  a  great  measure,  caused  by  the  pressure  of  the  enlarged  uterus ; 
in  fact,  any  condition  or  disease  affecting  the  mother,  provided  only 
we  are  convinced  that  the  termination  of  pregnancy  would  give  the 
patient  relief,  and  that  its  continuance  v/ould  involve  serious  danger. 
It  need  hardly  be  pointed  out  that  the  induction  of  labor  for  any 
such  causes  involves  grave  responsibility,  and  is  decidedly  open  to 
abuse;  no  practitioner  would,  therefore,  be  justified  in  resorting  to 
it,  especially  if  the  child  have  not  reached  a  viable  age,  without  the 
most  anxious  consideration.  No  general  rules  can  be  laid  down. 
Each  case  must  be  treated  on  its  own  merits.  It  is  obvious  that  the 
nearer  the  patient  is  to  the  full  period,  the  greater  will  be  the  chance 
of  the  child  surviving,  and  the  less  hesitation  need  then  be  felt  in 
consulting  the  interests  of  the  mother. 

Conditions  affecting  the  Safety  of  the  Child  alone. — In  another  class 
of  cases  the  operation  is  indicated  by  circumstances  affecting  the  life 
of  the  child  alone.  Of  these  the  most  common  are  those  in  which 
the  child  dies,  in  several  successive  pregnancies,  before  the  termina- 
tion of  utero-gestation.  This  is  generally  the  result  of  fatty,  calcare- 
ous, or  syphilitic  degeneration  of  the  placenta,  which  is  thus  rendered 
incapable  of  performing  its  functions.  These  changes  in  the  placenta 
seldom  commence  until  a  comparatively  advanced  period  of  preg- 
nancy ;   so  that  if  labor  be  somewhat  hastened,  we  may  hope  to 


444  OBSTETRIC  OPERATIONS. 

enable  the  patient  to  give  birtli  to  a  living  and  healthy  child.  The 
experience  of  the  naother  will  indicate  the  period  at  which  the  death 
of  the  fcetus  has  formerly  taken  place,  as  she  would  then  have  appre- 
ciated a  difference  in  her  sensations,  a  diminution  in  the  vigor  of  the 
foetal  movements,  a  sense  of  weight  and  coldness,  and  similar  signs. 
For  some  weeks  before  the  time  at  which  this  change  has  been  expe- 
rienced, we  should  carefully  auscultate  the  foetal  heart  from  day  to 
day,  and,  in  most  cases,  the  approach  of  danger  will  be  indicated 
sufficiently  soon  to  enable  us  to  interfere  with  success,  by  tumultuous 
and  irregular  pulsations,  or  a  failure  in  their  strength  and  frequency. 
On  the  detection  of  these,  or  on  the  mother  feeling  that  the  move- 
ments of  the  child  are  becoming  less  strong,  the  operation  should  at 
once  be  performed.  Simpson  also  induced  premature  labor  with 
success  in  a  patient  who  twice  gave  birth  to  hydrocephalic  children. 
In  the  third  pregnancy,  which  he  terminated  before, the  natural 
period,  the  child  was  well-formed  and  healthy. 

Induction  of  Labor  when  the  Mother  is  mortally  III. — Some  obstetri- 
cians have  proposed  to  induce  labor,  with  the  view  of  saving  the 
child,  when  the  mother  was  suffering  from  mortal  disease.  This 
indication  is,  however,  so  extremely  doubtful,  from  a  moral  point  of 
view,  that  it  can.  hardly  be  considered  as  ever  justifiable. 

Various  Methods  of  Inducing  Lahor  ;  their  mode  of  Action. — The 
means  adopted  for  the  induction  of  labor  are  very  numerous.  Some 
of  them  act  through  the  maternal  circulation,  as  the  administration 
of  ergot,  and  other  oxytocics ;  others  by  their  power  of  exciting  reflex 
action,  or  by  interfering  with  the  integrity  of  the  ovum,  or  by  a  com- 
bination of  both,  as  the  vaginal  douche,  separation  of  the  membranes 
from  the  iiterine  walls,  puncture  of  the  ovum,  dilatation  of  the  os, 
stimulating  enemata,  or  irritation  of  the  breasts.  The  former  class 
are  never  employed  in  modern  obstetric  practice.  Of  the  latter,  some 
offer  special  advantages  in  particular  cases,  but  none  are  equally 
adapted  for  all  emergencies.  Often  a  combination  of  more  methods 
than  one  will  be  found  most  useful.  I  shall  mention  the  various 
methods  in  use,  and  discuss  briefly  the  relative  advantages  and  dis- 
advantages of  each. 

Puncture  of  Membranes. — The  evacuation  of  the  liquor  amnii,  by 
the  puncture  of  the  membranes,  was  the  first  method  practised,  and 
was  that  recommended  by  Denman  and  all  the  earlier  writers.  It  is 
the  most  certain  which  can  be  employed,  as  it  never  fails,  sooner  or 
later,  to  induce  uterine  contractions  There  are,  however,  several 
disadvantages  connected  with  it,  which  are  sufficient  to  contra-indi- 
cate  its  use  in  the  majority  of  cases.  It  is  uncertain  as  regards  the 
time  taken  in  producing  the  desired  effect,  pains  sometimes  coming 
on  Avithin  a  few  hours,  but  occasionally  not  until  several  days  have 
elapsed.  The  contracting  walls  of  the  uterus  press  directly  on  the 
body  of  the  child,  which,  being  frail  and  immature,  is  less  liable  to 
bear  the  pressure  than  at  the  full  period  of  pregnancy.  Hence  it 
involves  great  risk  to  the  foetus.  Besides,  the  escape  of  the  water 
does  away  with  the  fluid  wedge  so  useful  in  dilating  the  os,  and 
should  version  be  necessary  from  mal-presentation — a  complication 


INDUCTION    OF    PREMATURE    LABOR.  445 

more  likely  to  occur  than  in  natural  labor — the  operation  would 
have  to  be  performed  under  very  unfavorable  conditions.  These 
objections  are  sufficient  to  justify  the  ordinary  opinion  that  this  pro- 
cedure should  not  be  adopted,  unless  other  means  had  been  tried  and 
failed.  Every  now  and  then  cases  are  met  with  in  which  it  is  ex- 
tremely difficult  to  arouse  the  uterus  to  action,  and  under  such 
circumstances,  in  spite  of  its  drawbacks,  this  method  will  be  found 
to  be  very  valuable.  When  the  operation  has  to  be  performed  before 
the  child  is  viable,  that  is,  before  the  seventh  month,  these  objections 
do  not  hold,  and  then  it  is  the  simplest  and  readiest  procedure  we 
can  adopt.  Indeed,  in  producing  early  abortion,  no  other  is  prac- 
ticable. The  operation  itself  is  most  simple,  requiring  only  a  quill, 
stiletted  catheter,  or  other  suitable  instrument,  to  be  passed  up  to 
the  OS,  carefully  guarded  by  the  fingers  of  the  left  hand  previously 
introduced,  and  to  be  pressed  against  the  membranes  until  perfora- 
tion is  acoraplished.  Meissner,  of  Leipsic,  has  proposed,  as  a  modi- 
fication of  this  plan,  that  the  membranes  should  be  punctured 
obliquely,  three  or  four  inches  above  the  os,  so  as  to  admit  of  a 
gradual  and  partial  escape  of  the  amniotic  fluid,  thus  lessening  the 
risk  to  the  child  from  pressure  by  the  uterus.  For  this  purpose  he 
employed  a  curved  silver  canula,  containing  a  small  trocar,  which 
can  be  projected  after  introduction.  The  risk  of  injuring  the  uterus, 
by  such  an  instrument,  would  be  considerable,  and  we  have  other 
and  better  means  at  our  command  which  render  it  unnecessary. 
When  we  require  to  produce  early  abortion,  it  would  be  well  not  to 
attempt  to  puncture  the  membranes  with  a  sharp  pointed  instrument. 
The  objection  can  be  effected  with  certainty,  and  greater  safety, 
by  passing  an  ordinary  uterine  sound  through  the  os,  and  turning  it 
round  once  or  twice. 

Administration  of  Oxytocics. — The  administration  of  ergot  of  rye, 
either  alone,  or  combined  with  borax  and  cinnamon,  has  been  some- 
times resorted  to.  This  practice  has  been  principally  advocated  by 
Ramsbotham,  who  was  in  the  habit  of  exhibiting  scruple  doses  of 
the  powdered  ergot  every  fourth  hour,  until  delivery  took  place. 
Sometimes  he  found  that  as  many  as  thirty  or  forty  doses  were  re- 
quired to  effect  the  object ;  occasionally  labor  commenced  after  a 
single  dose.  Finding  that  the  infantile  mortality  was  very  great 
when  this  method  was  followed,  he  modified  it,  and  admiiiistered 
two  or  three  doses  only,  and,  if  these  proved  insufficient,  he  punc- 
tured the  membranes.  There  can  be  no  doubt  that  ergot  possesses 
the  power  of  inducing  uterine  contractions.  The  risk  to  the  child 
is,  however,  quite  as  great  as  when  the  membranes  are  punctured ; 
for  not  only  is  it  subject  to  injurious  pressure  from  the  tumultous 
and  irregular  contractions  which  the  ergot  produces,  but  the  drug 
itself,  when  given  in  large  doses,  seems  to  exert  a  poisonous  influence 
on  the  foetus.  For  these  reasons  ergot  may  properly  be  excluded 
from  the  available  means  of  inducing  labor. 

Methods  actincj  Indirectly  on  the  Uterus. — Various  methods  have 
been  recommended  which  act  indirectly  on  the  uterus,  the  source  of 
irritation  being  at  a  distance.     Thus  D'Outrepont  used  frequently 


446 


OBSTETRIC    OPERATIONS, 


repeated  abdominal  frictions  and  tight  bandages.  Scanzoni,  remem- 
bering tlie  intimate  connection  between  the  mammae  and  uterus,  and 
the  tendency  which  irritation  of  the  former  has  to  induce  contraction 
of  the  latter,  recommended  the  frequent  application  of  cupping- 
glasses  to  the  breasts.  Radford  and  others  have  employed  galvanism. 
Stimulating  enemata  have  been  employed.  All  these  methods  have 
occasionally  proved  successful,  and  unlilve  the  former  plans  we  have 
mentioned,  they  are  not  attended  by  any  special  risk  to  the  child. 
They  are,  however,  much  too  uncertain  to  be  relied  on,  besides  being 
irksome  both  to  the  patient  and  practitioner. 

The  artificial  dilatation  of  the  os  uteri,  in  imitation  of  its  natural 
opening  in  labor,  was  first  practised  by  KlUge.  He  was  in  the  habit 
of  passing  within  the  os  a  tent  made  of  compressed  sponge,  and 
allowing  it  to  dilate  by  imbibition  of  fluid.  If  labor  were  not  pro- 
voked within  twenty- four  hours  be  removed  it,  and  introduced  one 
of  larger  dimensions,  changing  it  as  often  as  was  necessary  until  his 
object  was  accomplished.  Although  this  operation 
Fig.  142.  seldom  failed  to  induce  labor,  it  had  the  disadvan- 

tage of  occupying  an  indefinite  time,  and  the  irrita- 
tion produced  was  often  painful  and  annoying.     Dr. 
Keiller,  of  Edinburgh,  was  the  first  to  suggest  the 
use  of  caoutchouc  bags,  distended  by  air,  as  a  means  of 
dilating  the  os.     This  plan  has  been  perfected  by  Dr. 
Barnes  in  his  well-known  dilators,  which  are  of  great 
use  in  many  cases  in  which  artificial    dilatation  of 
the  cervix  is  necessary.     They  consist  of  a  series  of 
India-rubber  bags  of  various  sizes,    with  a  tube  at- 
tached  (Fig.  142),  through   which  water  can  be  in- 
jected by  an   ordinary  Higginson's  syringe.     They 
have  a  small  pouch   fixed    externally,  in  which   a 
sound  can  be  placed,  so  as  to  facilitate  their  intro- 
duction.    When  distended  with  water  the  bags  as- 
Barnes's  Ba?  for    sumc  somcwhat  of  a  fiddlc  shapc,  bulging  at  both 
Dilating  the  Cervix,     extrcmitics,  whicli  iusurcs  their  being  retained  within 
the  OS.     When  first  introduced  into  practice  as  a 
means  of  inducing  labor,  it  was   thought  that  this  method  gave  a 
complete  control  over  the  process,  so  that   it  could    be    concluded 
within  a  definite  time  at  the  will  of  the  operator.     The  experience  of 
those  w"ho  have  used  it  much  has  certainly  not  justified  this  anticipa- 
tion.    It  is  true  that,  occasionally,  contractions  supervene  within  a 
few  hours  after  dilatation  has  been  commenced;   but,  on  the  other 
hand,  the  uterus  often  responds  very    imperfectly  to   this  kind    of 
stimulus,  and  the  bags  may  be  inserted  for  many  consecutive  hours 
without  the  desired  result  supervening;   the  puncture  of  the  mem- 
branes being  evenmally  necessary  in  order  to  hasten  the  process. 
Indeed,  my  own  experience  Avould  lead  me  to  the  conclusion  that,  as 
a  means  of  evoking  uterine   contraction,  cervical  dilatation  is  very 
unsatisfactory.     Dr.  Barnes  himself  has    evidently  seen   reason  to 
modify  his  original  views,  for,  while  he  at  first  talked  of  the  bags  as 
enabling  us  to  induce  labor  with  certainty  at  a  given  time,  he  has 


INDUCTION    OF    PREMATURE    LABOR.  447 

since  recommended  that  uterine  action  should  be  first  provoked  by 
other  means,  the  dilators  being  subsequently  used  to  acccelerate  the 
labor  thus  brought  on.  The  bags  thus  employed  find,  as  I  believe, 
their  most  useful  and  a  very  valuable  application  ;  but  when  used 
in  this  way  they  cannot  be  considered  a  means  of  originating  uterine 
action,  A  subsidiary  objection  to  the  bags  is  the  risk  of  displacing 
the  presenting  part.  I  have,  for  example,  introduced  them  when 
the  head  was  presenting,  and,  on  their  removal,  found  the  shoulder 
lying  over  the  os.  It  is  not  difficult  to  understand  how  the  continu- 
ous pressure  of  a  distended  bag  in  the  internal  os  might  easily  push 
away  the  head,  which  is  so  readily  movable  as  long  as  the  mem- 
branes are  unruptured.  Still,  if  labor  be  in  progress,  and  the  os  in- 
sufficiently dilated,  the  possibility  of  this  occurrence  is  not  a  sufficient 
reason  for  not  availing  ourselves  of  the  undoubtedly  valuable  assist- 
ance which  the  dilators  are  capable  of  giving. 

Separation  of  the  Afemhranes. — Some  processes  for  inducing  labor 
act  directly  on  the  ovum,  by  separating  the  membranes,  to  a  greater 
or  less  extent,  from  the  uterine  walls.  The  first  procedure  of  the 
kind  was  recommended  by  Dr.  Hamilton,  of  Edinburgh,  and  con- 
sisted in  the  gradual  separation  of  the  membranes  for  one  or  two 
inches  all  round  the  lower  segment  of  the  uterus.  To  reach  them, 
the  finger  had  to  be  gently  insinuated  into  the  interior  of  the  os, 
which  was  gradually  dilated  to  a  sufficient  extent  by  a  series  of  suc- 
csssive  operations,  repeated  at  intervals  of  three  or  four  hours. 
When  this  had  been  accomplished,  the  fore-finger  was  inserted  and 
swept  round  between  the  membranes  and  the  uterus,  but  it  was  fre- 
quently found  necessary  to  introduce  the  greater  part  of  the  hand  to 
effect  the  object,  and,  sometimes,  even  this  was  not  sufficient,  and  a 
female  catheter  or  other  instrument  had  to  be  used  for  the  purpose. 
The  method  was  generally  successful  in  bringing  on  labor,  but  it 
now  and  then  failed,  even  in  Dr.  Hamilton's  hands.  It  is  certainly 
based  on  correct  principles,  but  it  is  tedious  and  painful  both  to  the 
practitioner  and  the  patient,  and  very  uncertain  in  its  time  of  action. 
For  these  reasons  it  has  never  been  much  practised. 

Vaginal  and  Uterine  Douches. — In  the  year  1836  Kiwisch  suggested 
a  plan  which,  from  its  simplicity,  has  met  with  much  approval.  It 
consists  in  projecting,  at  intervals,  a  stream  of  warm  or  cold  water 
against  the  os  uteri.  Its  action  is  doubtless  complex.  Kiwiscli  him- 
self believed  that  relaxation  of  the  soft  parts,  through  the  imbibition 
of  water,  was  the  determining  cause  of  labor.  Simpson  found  that 
the  method  failed,  unless  the  water  mechanically  separated  the  mem- 
branes from  the  uterine  walls.  Besides  this  effect,  it  probably  di- 
rectly induces  reflex  action,  by  distending  the  vagina  and  dilating  the 
os.  In  using  it,  it  has  been  customary  to  administer  a  douche  twice 
daily,  and  more  frequently  if  rapid  effects  be  desired.  The  number 
required  varies  in  different  cases.  The  largest  number  Kiwisch 
found  it  necessary  to  use  was  17,  the  smallest  4.  The  average  time 
that  elapses  before  labor  sets  in  is  four  days.  Hence  the  method  is 
obviously  useless  when  rapid  delivery  is  required. 

Dr.  Cohen,  of  Hamburgh,  introduced  an  important  modification  of 


4iS  OBSTETRIC  OPERATIONS. 

the  process,  wliicli  lias  been  considerablv  practised.  It  consists  in 
passing  a  silver  or  gum-elastic  catheter  some  inches  within  the  os, 
between  the  membranes  and  the  uterine  walls,  and  injecting  the  fluid 
tbrough  it  directly  into  the  cavity  of  the  uterus.  He  used  creasote, 
or  tar-water,  and  injected,  without  stopping,  until  the  patient  com- 
plained of  a  feeling  of  distension.  Others  have  found  the  plan 
equally  efl&cacious  when  they  only  employed  a  small  quantity  of 
plain  water,  such  as  7  or  8  ounces.  Professor  Lazarewitch,  of  Char- 
koft",  is  a  strong  advocate  of  this  method,  fie  believes  that  uterine 
action  is  evoked  much  more  rapidly  and  certainly  if  the  water  be 
injected  near  the  fundus,  and  he  has  contrived  an  instrument  for  the 
purpose,  with  a  long  metallic  nozzle. 

Dangers  of  these  Plans. — So  many  fatal  cases  have  folloAved  these 
methods,  that  it  cannot  be  doubted  that,  in  spite  of  their  certainty 
and  simplicity,  there  is  an  element  of  risk  in  them  that  should  not 
be  overlooked.  Many  of  these  are  recorded  in  Barnes's  work,  and 
he  comes  to  the  conclusion,  which  the  facts  unquestionably  justify, 
that  "the  douche,  whether  vaginal  or  intra-uterine,  ought  to  be  ab- 
solutely condemned  as  a  means  of  inducing  labor."  The  precise  rea- 
son of  the  danger  is  not  yerj  obvious.  Sudden  stretching  of  the 
uterine  walls,  producing  shock,  has  been  supposed  to  have  caused  it; 
but  in  many  of  the  fatal  cases  the  symptoms  have  been  rather  those 
attending  the  passage  of  air  into  the  veins,  and  it  is  easy  to  under- 
stand how  air  may  have  been  introduced,  in  this  way,  into  the  large 
uterine  sinuses. 

Injection  of  Carhonic  Acid  Gas. — Simpson  and  Scanzoni  have  both 
tried  with  success  the  injection  of  carbonic  acid  gas  into  the  vagina. 
Fatal  results  have,  however,  followed  its  employment,  and  Simpson 
has  expressed  an  opinion  that  the  experiment  should  not  be  re- 
peated. 

Simpson''s  Mode  of  Operating .—'&iva\)^o\'\  originally  induced  labor 
by  passing  the  uterine  sound  within  the  os,  and  up  towards  the  fun- 
dus, and,  when  it  had  been  inserted  to  a  sufficient  extent,  moving  it 
slightly  from  side  to  side.  He  was  led  to  adopt  this  procedure  in 
the  belief  that  we  might  thus  closely  imitate  the  separation  of  the 
decidua,  which  occurs  previous  to  labor  at  term.  Uterine  contrac- 
tions were  induced  with  certainty  and  ease,  but  it  was  found  impossi- 
ble to  foretell  what  time  might  elapse  between  the  commencement  of 
labor  and  the  operation,  which  had  frequently  to  be  2:)erformed  more 
than  once.  He  subsequently  modified  this  procedure  by  introducing 
a  flexible  male  catheter,  without  a  stilette,  which  he  allowed  to  re- 
main in  the  uterus  until  contractions  were  excited.  This  plan  is 
much  used  in  Germany,  and  is  now  that  which  is  also  most  fre- 
quentl}^  adopted  in  this  countr}^  It  is  simple  and  very  efficacious, 
pains  coming  on,  almost  invariably,  within  2-i  hours  after  the  cathe- 
ter or  bougie  is  introduced.  A  theoretical  objection  is  the  possi- 
bility of  the  catheter  separating  a  portion  of  the  placenta  and  giving 
rise  to  hemorrhage  ;  but  in  practice  this  has  not  been  found  to  occur, 
and  the  risk  might  generally  be  avoided  by  introducing  the  catheter 
at  a  distance  from  the  placenta,  the  probable  situation  of  which  has 


TURyiNG.  449 

been  ascertained  by  auscultation.  The  more  deeply  the  catheter  is 
introduced,  tlie  more  certain  and  rapid  is  its  effect,  and  not  less  than 
7  inches  should  be  pushed  up  within  the  os.  It  is  not  always  easy 
to  insert  it  so  far,  especially  if  a  flexible  catheter  be  used,  which  is 
apt  to  be  too  pliable  to  pass  upwards  Avith  ease.  A  solid  bougie — 
male  urethral  bougie— should,  therefore,  be  employed,  and  I  have 
found  its  introduction  greatly  facilitated  by  anaesthetizing  the  patient, 
and  passing  the  greater  part  of  the  hand  into  the  vagnia.  In  this 
way  it  can  be  pushed  in  very  gently,  and  without  any  risk  of  injury 
to  the  uterus.  There  is  some  chance  of  rupturing  the  membranes 
while  pushing  it  upwards.  This  accident,  indeed,  cannot  always  be 
avoided,  even  when  the  greatest  care  is  taken ;  but,  when  it  occurs, 
the  puncture  will  be  at  a  distance  from  the  os,  so  that  a  small  portion 
only  of  the  liquor  amnii  will  escape,  and  this  can  scarcely  be  con- 
sidered a  serious  objection.  It  is  always  an  advantage  to  allow  the 
pains  to  come  on  gradually,  and  in  imitation  of  natural  labor.  There- 
fore, if,  after  the  bougie  has  been  inserted  for  a  sufficient  time,  uterine 
contractions  come  on  sufficiently  strongly,  we  may  leave  the  case  to 
be  terminated  naturally  ;  or,  if  they  be  comparatively  feeble,  we  may 
resort  to  accelerative  procedures,  viz.,  dilatation  of  the  cervix  by  the 
fluid  bags,  and  subsequently  the  puncture  of  the  membranes.  In 
this  way  we  have  the  labor  completely  under  control ;  and  I  believe 
this  method  will  commend  itself  to  those  who  have  experience  of  it, 
as  the  simplest  and  most  certain  mode  of  inducing  labor  yet  known, 
and  the  one  most  closely  imitating  the  natural  process. 

The  Child  is  Immature  and  Difficult  to  Rear. — It  should  not  be  for- 
gotten that  the  child  is  immature,  and  that  unusual  care  is  likely  to 
be  required  to  rear  it  successfully.  We  should,  therefore,  be  careful 
to  have  at  hand  all  the  usual  means  of  resuscitation ;  and,  as  the 
mother  may  not  be  able  to  nurse  at  once,  it  would  be  a  good  pre- 
caution to  have  a  healthy  wet  nurse  in  readiness. 


CHAPTEE  II 

TURNING, 

Turning,  by  which  we  mean  the  alteration  of  the  position  of  the 
foetus,  and  the  substitution  of  some  other  portion  of  the  bod}^  for 
that  originally  presenting,  is  one  of  the  most  important  of  obstetric 
operations,  and  merits  careful  study.  It  is  also  one  of  the  most 
ancient,  and  was  evidently  known  to  the  Greek  and  Eoman  phj^si- 
cians.  Up  to  the  fifteenth  century,  cephalic  version — that  in  which 
the  head  of  the  foetus  is  brought  over  the  os  uteri —  was  almost 
exclusively  practised,  when  Pare  and  his  pupil  Guillemeau  taught 


450  OBSTETillC    OPERATIONS. 

the  propriety  of  bringing  the  feet  down  first.  It  was  by  tlie  latter 
pliysiciau  especially  that  the  steps  of  the  operation  were  clearly 
defined ;  and  the  French  have  undoubtedly  the  merit  both  of  per- 
fecting its  performance,  and  of  establishing  the  indications  which 
should  lead  to  its  use.  Indeed,  it  was  then  much  more  frequently 
performed  than  in  later  times,  since  no  other  means  of  effecting  arti- 
ficial delivery  were  known,  which  did  not  involve  the  death  of  the 
child ;  and  practitioners,  doubtless,  acquired  great  skill  in  its  per- 
formance, and  were  inclined  to  overrate  its  importance,  and  extend 
its  use  to  unsuitable  cases.  An  opposite  error  was  fallen  into  after 
the  invention  of  the  forceps,  which  for  a  time  led  to  the  abandonment 
of  turning  in  certain  conditions  for  which  it  was  well  adapted,  and 
in  which  it  has  only  of  late  years  been  again  practised.- 

Cephalic  version  has,  since  Pare  wrote,  been  recommended  and 
practised  from  time  to  time,  but  the  difficulty  of  performing  it  satis- 
factorily was  so  great  that  it  never  became  an  established  operation. 
Dr.  Braxton  Hicks  has  perfected  a  method  by  which  it  can  be  ac- 
complished with  greater  ease  and  certainty,  and  which  renders  it  a 
legitimate  and  satisfactory  resort  in  suitable  cases.  To  him  we  are 
also  indebted  for  introducing  a  method  of  turning  without  passing 
the  entire  hand  into  the  cavity  of  the  uterus,  which,  under  favorable 
circumstances,  is  not  only  easy  of  performance,  but  deprives  the 
operation  of  one  of  its  greatest  dangers. 

Turning  hy  External  and  Internal  Manipulation.- — -The  possibility 
of  effecting  version  by  external  manipulation  has  been  long  known, 
and  was  distinctly  referred  to  and  recommended  by  Dr.  John  Pechey,^ 
so  far  back  as  the  year  1698.  Since  that  time  it  has  been  strongly 
advocated  by  Wigand  and  his  followers  ;  and  various  authors  in  this 
country,  notably  Sir  James  Simpson,  have  referred  to  the  advantage 
to  be  derived  from  external  manipulation  assisting  the  hand  in  the 
interior  of  the  uterus.  In  185-1:  Dr.  Wright,  of  Cincinnati,  advocated 
the  application  of  the  bi- manual  method  in  arm  and  shoulder  pre- 
sentations, chiefly  with  the  view  of  effecting  cephalic  version.  To 
Dr.  Hicks,  however,  incontestably  belongs  the  merit  of  having  been 
the  first  distinctly  to  show  the  possibility  of  effecting  complete  version 
in  all  cases  in  which  the  operation  is  indicated  by  combined  external 
and  internal  manipulation,  of  laying  down  definite  rules  for  its  prac- 
tice, and  of  thus  popularizing  one  of  the  greatest  imDrovements  in 
modern  midwifery, 

Ohject  and  Nature  of  the  Operation. — The  operation  is  entirely 
dependent  for  success  on  the  fact  that  the  child  in  utero  is  freely 
movable,  and  that  its  position  may  be  artificially  altered  with 
facility  As  long  as  the  membranes  are  unruptured,  and  the  foetus 
is  floating  in  the  surrounding  fluid  medium,  it  is  liable  to  constant 
changes  in  position,  as  may  be  readily  demonstrated  in  the  latter 
months  of  pregnancy ;  and  the  operation,  under  these  circumstances, 
may  be  performed  with  the  greatest  facility.  Shortly  after  the  liquor 
amnii  has  escaped  there  is  still,  as  a  rule,  no  great  difficulty  in  effect-^ 

1  The  Complete  Midwife's  Practice,  p.  142. 


TURNING.  451 

ino-  version;  but,  as  the  body  is  no  longer  floating  in  the  surround- 
ino-  liquid,  its  rotation  must  necessarily  be  attended  with  some 
increased  ris^  of  injury  to  the  uterus.  If  the  liquor  amnii  have 
been  lono-  evacuated,  and  the  muscular  structure  of  the  uterus  be 
strongly  contracted,  the  foetus  may  be  so  firmly  fixed,  that  any 
attempt  to  move  it  is  surrounded  with  the  greatest  difficulties,  and 
may  even  fail  entirely,  or  be  attended  with  such  risks  to  the  maternal 
structures  as  to  be  quite  unjustifiable. 

Gases  Suitable  for  the  Operation. — Version  may  be  required  either 
on  account  of  the  mother  or  child  alone;  or  it  may  be  indicated  by 
some  condition  imperilling  both,  and  rendering  immediate  delivery 
necessary.  The  chief  cases  in  which  it  is  resorted  to  are  those  of 
transverse  presentation,  where  it  is  absolutely  essential;  accidental 
or  unavoidable  hemorrhage;  certain  cases  of  contracted  pelvis;  and 
some  complications,  especially  prolapse  of  the  funis.  The  special 
indications  for  the  operation  have  been  separately  discussed  under 
these  subjects. 

Statistics  and  Dangers  of  the  Oxjeration. — The  ordinary  statistical 
tables  cannot  be  depended  on  as  giving  any  reliable  results  as  to  the 
risks  of  the  operation.  Taking  all  cases  together.  Dr.  Churchill  esti- 
mates the  maternal  mortality  as  1  in  16,  and  the  infantile  as  1  in  3. 
Like  all  similar  statistics,  they  are  open  to  the  objection  of  not  dis- 
tinguishing between  the  results  of  the  operation  itself,  and  of  the 
cause  which  necessitated  interference.  Still  they  are  sufl&cient  to 
show  that  the  operation  is  not  free  from  grave  hazards,  and  that  it 
must  not  be  undertaken  without  due  reflection.  The  principal 
dangers  will  be  discussed  as  we  proceed.  It  may  suffice  to  mention 
here  that  those  to  the  mother  must  vary  Avith  the  period  at  which 
the  operation  is  undertaken.  If  version  be  performed  early,  before 
the  rupture  of  the  mem'branes,  or,  in  favorable  cases,  without  the 
introduction  of  the  hand  into  the  interior  of  the  uterus,  the  risk 
must  of  course  be  infinitely  less  than  in  those  more  formidable  cases 
in  which  the  waters  have  long  escaped,  and  the  hand  and  arms  have 
to  be  passed  into  an  irritable  and  contracted  uterus.  But  even  in 
the  most  unfavorable  cases  accidents  may  be  avoided,  if  the  operator 
bear  constantly  in  mind  that  the  principal  danger  consists  in  lace- 
ration of  the  uterus  or  vagina  from  undue  force  being  employed,  or 
from  the  hand  and  arm  not  being  introduced  in  the  axis  of  the  pas- 
sages. There  is  no  operation  in  Avhich  gentleness,  absence  of  all 
hurry,  and  complete  presence  of  mind  are  so  essential.  A  certain 
number  of  cases  end  fatally  from  shock  or  exhaustion,  or  from  sub- 
sequent complications.  As  regards  the  child,  the  mortality  is  little, 
if  at  all,  greater  than  in  original  breech  and  footling  presentations. 
Nor  is  there  any  good  reason  why  it  should  be  so,  seeing  that  cases 
of  turning,  after  the  feet  are  brought  through  the  os,  are  virtually 
reduced  to  those  of  feet  presentation,  and  that  the  mere  version,  if 
efl'ected  sufficiently  soon,  is  not  likely  to  add  materially  to  the  risk 
to  which  the  child  is  exposed. 

Version  hy  External  Manipulation. — The  possibility  of  effecting 
version  hy  external  'manipulation  has  been  recognized  by  various 


452  OBSTETRIC  OPERATIONS. 

authors,  aud  was  made  the  subject  of  an  excellent  thesis  by  Wigand, 
who  GJearlj  described  the  manner  of  performing  the  operation.  In 
spite  of  the  manifest  advantages  of  the  procedure,  and  the  extreme 
facility  with  which  it  can  be  accomplished  in  saitable  cases,  it  has 
bj  no  means  become  the  established  custom  to  trust  to  it,  and  prob- 
ably most  practitioners  have  never  attempted  it,  even  under  the  most 
favorable  conditions.  The  possibility  of  operation  is  based  on  the 
extreme  mobility  of  the  foetus  before  the  membranes  are  ruptured. 
After  the  waters  have  escaped,  the  uterine  walls  embrace  the  foetus 
more  or  less  closely,  and  version  can  no  longer  be  readily  performed 
in  this  manner. 

Cases  suitahle  for  the  Operation. — It  may,  therefore,  be  laid  down 
as  a  rule  that  it  should  only  be  attempted  when  the  abnormal  posi- 
tion of  the  foetus  is  detected  before  labor  has  commenced,  or  in  the 
early  stage  of  labor,  when  the  membranes  are  ruptured.  It  is 
also  unsuitable  for  any  but  transverse  presentations,  for  it  is  not 
meant  to  effect  complete  evolution  of  the  foetus,  but  only  to  substi- 
tute the  head  for  the  upper  extremity.  It  is  useless  whenever  rapid 
delivery  is  indicated,  for,  after  the  head  is  brought  over  the  brim, 
the  conclusion  of  the  case  must  be  left  to  the  natural  powers. 

Method  of  Performance. — The  manner  of  detecting  the  presentation 
by  palpation  has  been  already  described  (p.  116),  and  the  success  of 
the  operation  depends  on  our  being  able  to  ascertain  the  positions  of 
the  head  and  breech  through  the  uterine  walls.  Should  labor  have 
commenced,  and  the  os  be  dilated,  the  transverse  presentation  may  be 
also  made  out  by  vaginal  examination.  Should  the  abnormal  pre- 
sentation be  detected  before  labor  has  actually  begun,  it  is,  in  most 
cases,  easy  enough  to  alter  it,  and  to  bring  the  foetus  into  the  longi- 
tudinal axis  of  the  uterine  cavity.  Pinard^  recommends  that  after 
this  has  been  done  the  foetus  should  be  maintained  in  position  by  a 
well-fitting  elastic  abdominal  belt.  It  is  seldom,  however,  discovered 
until  labor  has  commenced,  and  even  if  it  be  altered,  the  child  is  ex- 
tremely apt  to  resume,  in  a  short  time,  the  faulty  position  in  which 
it  was  formerly  lying.  Still  there  can  be  no  harm  in  making  the 
attempt,  since  the  operation  itself  is  in  no  way  painful,  and  is  abso- 
lutely without  risk  either  to  the  mother  or  child.  When  the  trans- 
verse presentation  is  detected  early  in  labor,  I  believe  it  is  good 
practice  to  endeavor  to  remedy  it  by  external  manipulation,  and,  if 
it  fail,  we  may  at  once  proceed  to  other  and  more  certain  methods 
of  operating.  The  procedure  itself  is  abundantly  simple.  The  pa- 
tient is  placed  on  her  back,  and  the  position  of  the  foetus  ascertained 
by  palpation  as  accurately  as  possible,  in  the  manner  already  indi- 
cated. The  palms  of  the  hands  being  then  placed  over  the  opposite 
poles  of  the  foetus,  by  a  series  of  gentle  gliding  movements,  the  head 
is  pushed  towards  the  pelvic  brim,  while  the  breech  is  moved  in  the 
opposite  direction.  The  facility  with  which  the  foetus  may  some- 
times be  moved  in  this  way  can  hardly  be  appreciated  by  those  who 
have  never  attempted  the  operation.      As  soon  as  the  change  is 

De  la  version  par  manoeuvres  externes.    Paris,  1878. 


TURNING.  453 

effected,  the  long  diameters  of  tlie  foetus  and  of  the  uterus  will  cor- 
respond, and  vaginal  examination  will  show  that  the  shoulder  is  no 
longer  presenting,  and  that  the  head  is  over  the  pelvic  brim.  If 
the  OS  be  snfficientlj  dilated,  and  labor  in  progress,  the  membranes 
should  now  be  punctured,  and  the  position  of  the  foetus  maintained 
for  a  short  time  by  external  pressure,  until  we  are  certain  that  the 
cephalic  presentation  is  permanently  established.  If  labor  be  not  in 
progress,  an  attempt  may  at  least  be  made  to  effect  the  same  object 
by  pads  and  a  binder  ;  one  pad  being  placed  on  the  side  of  the  uterus 
in  the  situation  of  the  breech,  and  another  on  the  o[)posite  side  in 
the  situation  of  the  head. 

Cephalic  Version. — On  account  of  the  difficulty  of  performing  cejiha- 
lic  version  in  the  manner  usually  recommended,  it  has  practically 
scarcely  been  attempted,  and  Avith  the  exception  of  some  more  recent 
authors,  it  is  generally  condemned  by  writers  on  systematic  mid- 
wifery. Still  the  operation  offers  unquestionable  advantages  in  those 
transverse  presentations  in  which  rapid  delivery  is  not  necessary, 
and  in  which  the  only  object  of  interference  is  the  rectification  of 
malposition ;  for,  if  successful,  the  child  is  spared  the  risk  of  being 
drawn  footling  through  the  pelvis.  The  objections  to  cephalic  ver- 
sion are  based  entirely  on  the  difficulty  of  performance ;  and,  un- 
doubtedly, to  introduce  the  hand  within  the  uterus,  search  for,  seize, 
and  afterwards  place  the  slippery  head  in  the  brim  of  the  pelvis, 
could  not  be  an  easy  process,  even  under  the  most  favorable  circum- 
stances, and  must  always  be  attended  by  considerable  risk  to  the 
mother.  Velpeau,  who  strongly  advocated  the  operation,  was  of 
opinion  that  it  might  be  more  easily  accomplished  by  pushing  up  the 
presenting  part,  than  by  seizing  and  bringing  down  the  head.  Wi- 
gand  more  distinctly  pointed  out  that  the  head  could  be  brought  to 
a  proper  position  by  external  manipulation,  aided  by  the  fingers  of 
one  hand  within  the  vagina.  Braxton  Hicks  has  laid  down  clear 
rules  for  its  performance,  which  render  cephalic  version  easy  to  ac- 
complish under  favorable  conditions,  and  will  doubtless  cause  it  to 
become  a  recognized  mode  of  treating  malpositions.  The  number  of 
cases,  however,  in  which  it  can  be  performed  must  always  be  limited 
since,  as  in  turning  by  external  manipulation  alone,  it  is  necessary 
that  the  liquor  amnii  should  be  still  retained,  or  at  least  have  only 
recently  escaped ;  that  the  presentation  be  freely  movable  above  the 
pelvic  brim;  and  that  there  be  no  necessity  for  rapid  delivery.  Dr. 
Hicks  does  not  believe  protrusion  of  the  arm  to  be  a  contra-indica- 
tion,  and  advises  that  it  should  be  carefully  replaced  within  the 
uterus.  When,  hoAvever,  protrusion  of  the  arm  has  occurred,  the 
thorax  is  so  constantly  pushed  down  into  the  pelvis  that  replacement 
can  neither  be  safe  nor  practicable,  except  under  unusually  favorable 
conditions,  and  podalic  version  will  be  necessary. 

Method  of  Performance. — It  is  impossible  to  describe  the  method 
of  performing  cephalic  version  more  concisely  and  clearly  than  in 
Dr.  p[icks's  own  words.  "Introduce,"  he  says,  "the  left  hand  into 
the  vagina,  as  in  podalic  version  ;  place  the  right  hand  on  the  out- 
side of  the  abdomen,  in  order  to  make  out  the  position  of  the  foetus, 


454  OBSTETRIC  OPERATIONS. 

and  tlie  direction  of  its  iiead  and  feet.  Should  the  shoulder,  for 
instance,  present,  then  push  it  with  one  or  two  fingers  in  the  direc- 
tion of  the  feet.  At  the  same  time  pressure  with  the  other  hand 
should  be  exerted  on  the  cephalic  end  of  the  child.  This  will  bring 
the  head  down  to  the  os ;  then  let  the  head  be  received  on  the  tips 
of  the  inside  fingers.  The  head  will  play  like  a  ball  between  the 
two  hands ;  it  will  be  under  their  command,  and  can  be  placed  in 
almost  any  part  at  will.  Let  the  head  then  be  placed  over  the  os, 
taking  care  to  rcctifj  any  tendency  to  face  presentation.  It  is  as 
well,  if  the  breech  will  not  rise  to  the  fundus  readily  after  the  head 
is  fairly  in  the  os,  to  withdraw  the  hand  from  the  vagina,  and  with 
it  press  up  the  breech  from  the  exterior.  The  hand  which  is  re- 
taining gently  the  head  from  the  outside  should  continue  there  for 
some  little  time  till  the  pains  have  insured  the  retention  of  the  child 
in  its  new  position  and  the  adaptation  of  the  uterine  walls  to  its  new 
form.  Should  the  membranes  be  perfect,  it  is  advisable  to  rupture 
them  as  soon  as  the  head  is  at  the  os  uteri ;  during  their  flow  and 
after  the  head  will  move  easily  into  its  proper  position." 

The  procedure  thus  described  is  so  simple,  and  would  occupy  so 
short  a  time,  that  there  can  be  no  objection  to  trying  it.  Should  we 
fail  in  our  endeavors,  we  shall  not  be  in  a  worse  position  for  efi'ecting 
delivery  by  podalic  version,  which  can  be  proceeded  with  without 
withdrawing  the  hand  from  the  vagina,  or  in  any  way  altering  the 
position  of  the  patient. 

Podalic  Version. — The  method  of  performing  podalic  version  varies 
with  the  nature  of  each  particular  case.  In  describing  the  operation, 
it  has  been  usual  to  divide  the  cases  into  those  in  which  the  circum- 
stances are  favorable,  and  the  necessary  manoeuvres  easily  accom- 
plished ;  and  those  in  which  there  are  likely  to  be  considerable  diffi- 
culties, and  increased  risk  to  the  mother.  This  division  is  eminently 
practicable,  since  nothing  can  be  more  variable  than  the  circum- 
stances under  which  version  may  be  required.  Before  describing 
the  steps  of  the  operation,  it  may  be  well  to  consider  some  general 
conditions  applicable  to  all  cases  alike. 

Position  of  the  Patient. — In  this  country  the  ordinary  position  on 
the  left  side  is  usually  employed.  On  the  Continent  and  in  America 
the  patient  is  placed  on  her  back,  with  the  legs  supported  by  assist- 
ants, as  in  lithotomy.  The  former  position  is  preferable,  not  only 
as  a  matter  of  custom,  and  as  involving  much  less  fuss  and  exposure 
of  the  person,  but  because  it  admits  of  both  the  operator's  hands 
being  more  easily  used  in  concert.  In  certain  difficult  cases,  when 
the  liquor  amnii  has  escaped,  and  the  back  of  the  child  is  turned 
towards  the  spine  of  the  mother,  the  dorsal  decubitis  presents  some 
advantages  in  enabling  the  hand  to  pass  more  readily  over  the  body 
of  the  child ;  but  such  cases  are  comparatively  rare.  The  patient 
should  be  brought  to  the  side  of  the  bed,  across  which  she  should 
be  laid,  with  the  hips  projecting  over,  and  parallel  to,  the  edge,  the 
knees  being  flexed  towards  the  abdomen,  and  separated  from  each 
other  by  a  pillow,  or  by  an  assistant.  Assistants  should  also  be 
placed  so  as  to  restrain  the  patient  if  necessary,  and  prevent  her 


TURNING.  455 

involuntarily  starting  from  the  operator,  as  this  might  not  only 
embarrass  his  movements,  but  be  the  cause  of  serious  injury. 

Administration  of  Anesthetics. — The  exhibition  of  autesthetics  is 
peculiarly  advantageous.  There  is  nothing  which  tends  to  faciUtate 
the  steps  of  the  process  so  much  as  stillness  on  the  part  of  the 
patient,  and  the  absence  of  strong  uterine  contraction.  When  the 
vagina  is  very  irritable  and  the  uterus  firmly  contracted  round  the 
body  of  the  child,  complete  antesthesia  may  enable  us  to  eflect  ver- 
sion, when  without  it  we  should  certainly  fail. 

Period  when  the  Operation  should  he  Undertaken. — The  most  favor- 
able time  for  operating  is  when  the  os  is  fully  dilated,  before,  or  im- 
mediately after,  the  rupture  of  the  membranes  and  the  discharge  of 
the  liquor  aranii.  The  advantage  gained  by  operating  before  the 
waters  have  escaped  cannot  be  overstated,  since  we  can  then  make 
the  child  rotate  with  great  facility  in  the  fluid  medium  in  which  it 
floats.  In  the  ordinary  operation,  in  which  the  hand  is  passed  into 
the  uterus,  it  is  essential  to  wait  until  the  os  is  of  sufficient  size  to 
admit  its  being  introduced  with  safety.  This  may  generally  be  done 
when  the  os  is  the  size  of  a  crown-piece,  especially  if  it  be  soft  and 
yielding. 

Choice  of  Hand  to  he  7ised. — The  practice  followed  with  regard  to 
the  hand  to  be  used  in  turning  varies  considerably.  Some  accoucheurs 
always  employ  the  right  hand,  others  the  left,  and  some  one  or  other, 
according  to  the  position  of  the  child.  In  favor  of  the  right  hand, 
it  is  said  that  most  practitioners  have  more  power  with  it,  and  are 
able  to  use  it  with  greater  gentleness  and  delicacy.  In  transverse 
presentations,  if  the  abdomen  of  the  child  be  placed  anteriorly,  the 
right  hand  is  said  to  be  the  proper  one  to  use,  on  account  of  the 
greater  facility  with  which  it  can  be  passed  over  the  front  of  the 
child  ;  and  in  difficult  cases  of  this  kind,  when  we  are  operating  with 
the  patient  on  her  back,  it  certainly  can  be  employed  with  more  pre- 
cision than  the  left.  In  all  ordinary  cases,  however,  the  left  hand 
can  be  introduced  much  more  easily  in  the  axis  of  the  passages,  the 
back  of  the  hand  adapts  itself  readily  to  the  curve  of  the  sacrum, 
and,  even  when  the  child's  abdomen  lies  anteriorly,  it  can  be  passed 
forwards  without  difficulty  so  as  to  seize  the  feet.  These  advantages 
are  sufficient  to  recommend  its  use,  and  very  little  practice  is  re- 
quired to  enable  the  practitioner  to  manipulate  with  it  as  freely  as 
withthe  right.  If,  in  addition,  we  remember  that  the  right  hand  is 
required  to  operate  on  the  foetus  through  the  abdominal  walls — and 
this  is  a  point  which  should  never  be  forgotten — we  shall  have 
abundant  reasons  for  laying  it  down  as  a  rule  that  the  left  hand 
should  generally  be  employed.  Before  passing  the  hand  and  arm 
they  should  be  freely  lubricated,  with  the  exception  of  the  palm, 
which  is  left  untouched  to  admit  of  a  firm  grasp  being  taken  of  the 
foetal  linibs.  It  is  also  advisable  to  remove  the  coat,  and  bare  the 
arm  as  high  as  the  elbow. 

As  it  should  be  a  cardinal  rule  to  resort  to  the  simplest  procedure 
when  practicable,  it  will  be  well  to  consider  first  the  method  by  com- 
bined external  and  internal  manipulation,  without  passing  the  hand 


456 


OBSTETRIC    OPERATIONS, 


into  tlie  uterus,  and  subsequently  that  which  involves  the  introduc- 
tion of  the  hand. 

TurniiKj  hy  Combined  External  and  Internal  Man%iyidation. — To 
effect  podalic  version  by  the  combined  method  it  is  an  essential  pre- 
liminary to  ascertain  the  situation  of  the  foetus  as  accurately  as  pos- 
sible. It  will  generally  be  easy,  in  transverse  presentation,  to  make 
out  the  breech  and  the  head  by  palpation ;  while,  in  head  presenta- 
tions, the  fontanelles  will  show  to  which  side  of  the  pelvis  the  face 
is  turned.  The  left  hand  is  then  to  be  passed  carefully  into  the 
vagina,  in  the  axis  of  the  canal,  to  a  sufficient  extent  to  admit  of  the 
fingers  passing  freely  into  the  cervix.  To  effect  this,  it  is  not  always 
necessary  to  insert  the  whole  hand,  three  or  four  fingers  being  gen- 
erally sufficient. 


Fig.  143. 


First  Stage  of  Bipohir  Version- 


-Elevation  of  the  Head  and  Depression  of  the  Breech. 
(After  Barnes.) 


If  the  head  lie  in  the  first  or  fourth  position,  push  it  upwards  and 
to  the  left ;  Avhile  the  other  hand,  placed  externally  on  the  abdomen, 
depresses  the  breech  toAvards  the  right  (Fig.  144).  By  this  means 
we  act  simultaneously  on  both  extremities  of  the  child's  body,  and 
easily  alter  its  position.  The  breech  is  pushed  down  gently  but 
firmly,  by  gliding  the  hand  over  the  abdominal  wall.  The  head  will 
now  pass  out  of  reach,  and  the  shoulder  will  arrive  at  the  os,  and 
will  lie  on  the  tips  of  the  fingers.  This  is  similarly  pushed  upwards 
in  the  same  direction  as  the  head  (Fig.  144),  the  breech  at  the  same 


TURNING.  457 

time  being  still  further  depressed,  until  the  knee  comes  within  reach 
of  the  fingers,  when  (the  mernbraues  being  now  ruptured,  if  still 

Fig.  144. 


Second  Stage  of  Bi-polar  Version. — Elevation  of  the  Shoulders  and  Depression  of  the  Breech. 

(After  Barnes.) 

unbroken)  it  is  seized  and  pulled  down  through  the  os  (Fig.  145). 
Occasionally  the  foot  comes  immediately  over  the  os,  when  it  can  be 
seized  instead  of  the  knee.     Yersion  may  be  facilitated  by  changing 

Fig.  145. 


Third  Stage  of  Bi-polar  Version.— Seizure  of  the  Knee  and  partial  Elevation  of  the  Head. 

(After  Barnes.) 

the  position  of  the  external  hand,  and  pushing  the  head  upwards 
from  the  iliac  fossa,  instead  of  continuing  the  attempt  to  depress  the 


458 


OBSTETRIC    OPERATIONS. 


breech  (Figs.  145  and  146).  These  manipulations  should  always  Le 
carried  on  in  the  intervals,  and  desisted  from  when  the  pains  come 
on ;  and  when  the  pains  recur  with  great  force  and  frequency,  the 
advantage    of  chloroform  will   be    particularly   apparent.     In    the 


Fig.  146. 


Fourth  Stage  of  Bi-polar  Version. — Drawing  down  of  the  Legs  and  completion  of  version. 

(After  Barnes.) 

second  and  third  positions,  the  steps  of  the  operation  should  be  re- 
versed ;  the  head  is  pushed  upwards  and  to  the  right,  the  breech 
downwards  and  to  the  left.  When  the  position  cannot  be  made  out 
with  certainty,  it  is  well  to  assume  that  it  is  the  first,  since  that  is 
the  one  most  frequently  met  with ;  and  even  if  it  be  not,  no  great 
inconvenience  is  likely  to  occur.  If  the  os  be  not  sufficiently  open 
to  admit  of  delivery  being  concluded,  the  lower  extremity  can  be 
retained  in  its  new  position  with  one  finger,  until  dilatation  is  suffi- 
ciently advanced,  or  until  the  uterus  has  permanently  adapted  itself 
to  the  altered  position  of  the  child,  either  of  which  results  will  gene- 
rally be  effected  in  a  short  space  of  time. 

In  transverse  presentations  the  same  means  are  to  be  adopted,  the 
shoulder  being  pushed  upwards  in  the  direction  of  the  head,  while 
the  breech  is  depressed  from  without.  This  is  frequently  sufficient 
to  bring  the  knees  within  reach,  especially  if  the  membranes  are 
entire,  tjut  version  is  much  facilitated  by  pressing  the  head  upwards 
from  without,  alternately  with  depression  of  the  breech.  If  the 
liquor  amnii  has  escaped,  and  the  uterus  is  firmly  contracted  round 
the  body  of  the  child,  it  will  be  found  impossible  to  effect  an  altera- 
tion in  its  position  without  the  introduction  of  the  hand,  and  the 


TURNING.  459 

ordinary  method  of  turning  must  be  employed.  Tiie  peculiar  advan- 
tage of  the  combined  process  is,  that  it  in  no  way  interferes  with  the 
latter,  for,  should  it  not  succeed,  the  hand  can  be  passed  on  into  the 
uterus  without  withdrawal  from  the  vagina  (provided  the  os  be 
sufficiently  dilated),  and  the  feet  or  knees  seized  and  brought  down. 

Podalic  Version  when  the  Hand  is  introduced  into  the  Uterus. — Turn- 
ing, with  the  hand  introduced  into  the  uterus,  provided  the  waters 
have  not  or  have  only  recently  escaped,  and  the  os  be  sufficiently 
dilated,  is  an  operation  generally  performed  with  ease. 

Introduction  of  the  Hand. — The  first  step,  and  one  of  the  most 
important,  is  the  introduction  of  the  hand  and  arm.  The  fingers 
having  been  pressed  together  in  the  form  of  a  cone,  the  thumb  lying 
between  the  rest  of  the  fingers,  the  hand,  thus  reduced  to  the  smallest 
possible  dimensions,  is  slowly  and  carefully  passed  into  the  vagina, 
in  the  axis  of  the  outlet,  in  an  interval  between  the  pains,  and  passed 
onwards  in  the  same  cautious  manner,  and  with  a  semi-rotatory 
motion,  until  it  lies  entirely  within  the  vagina,  the  direction  of  in- 
troduction being  gradually  changed  from  the  axis  of  the  outlet  to 
that  of  the  brim.  If  uterine  contractions  come  on,  the  hand  should 
remain  passive  until  they  are  over.  It  should  ever  be  borne  in 
mind,  as  one  of  the  fundamental  rules  in  performing  version,  that 
we  should  act  only  in  the  absence  of  pains,  and  then  with  the  utmost 
gentleness — all  force  and  violent  pushing  being  avoided.  The  hand, 
still  in  the  form  of  a  cone,  having  arrived  at  the  os,  if  this  be  suffi- 
ciently dilated,  may  be  passed  through  at  once.  If  the  os  be  not 
quite  open,  but  dilatable,  the  points  of  the  fingers  may  be  gently 
insinuated,  and  occasionally  expanded,  so  as  to'  press  it  open  suffi- 
ciently to  permit  the  rest  of  the  hand  to  pass.  While  this  is  being 
done,  the  uterus  should  be  steadied  by  the  other  hand  placed  exter- 
nally, or  by  an  assistant.  If  the  presentation  should  not  previously 
have  been  made  out  with  accuracy,  Ave  can  now  ascertain  how  to 
pass  the  hand,  onwards,  so  that  its  palmar  surface  may  correspond 
with  the  abdomen  of  the  child. 

Biupture  of  the  Membranes. — The  membranes  should  now  be  rup- 
tured— if  possible  during  the  absence  of  pain — -so  as  to  prevent  the 
waters  being  forced  out.  The  hand  and  arm  form  a  most  efficient 
plug,  and  the  liquor  amnii  cannot  escape  in  any  quantity.  Some 
practitioners  recommend  that,  before  rupturing  the  membranes,  the 
hand  should  be  passed  onwards  between  them  and  the  uterine  walls, 
until  we  reach  the  feet.  By  so  doing  we  run  the  risk  of  separating 
the  placenta ;  besides  we  have  to  introduce  the  hand  much  further 
than  may  be  necessary,  since  the  knees  are  often  found  lying  quite 
close  to  the  os.  As  soon  as  the  membranes  are  perforated,  the  hand 
can  be  passed  on  in  search  of  the  feet  (Fig.  147).  At  this  stage  of 
the  operation  increased  care  is  necessary  to  avoid  anything  like 
force ;  and  should  a  pain  come  on,  the  hand  must  be  kept  perfectly 
flat  and  still,  and  rather  pressed  on  the  body  of  the  child  than  on  the 
uterus.  If  the  pains  be  strong,  much  inconvenience  may  be  felt  from 
the  compression ;  and,  were  the  onward  movement  continued,  or  the 
hand  even  kept  bent  in  the  conical  form  in  which  it  was  introduced, 


460 


OBSTETRIC    OPERATIONS. 


rupture  of  the  uterine  walls  miglit  easily  be  caused.  This  is  not 
likely  to  occur  in  the  class  of  cases  now  under  consideration,  for  it 
is  chiefly  when  the  waters  have  long  escaped  that  the  progress  of  the 
hand  is  a  matter  of  difficulty.     Valuable  assistance  may  now  be  given 


Fig.  147. 


Seizure  of  the  Feet  when  the  Hand  is  Introduced  into  the  Uterus. 

by  pressing  the  breech  downwards  from  without,  so  as  to  bring  the 
knees  or  feet  more  easily  within  the  reach  of  the  internal  hand. 
Having  arrived  at  the  knees  or  feet,  they  may  be  seized  between  the 
fingers,  and  drawn  downwards  in  the  absence  of  a  pain  (Fig.  148). 
This  will  cause  the  foetus  to  revolve  on  its  axis,  the  breech  will  de- 
scend, and,  at  the  same  time,  the  ascent  of  the  head  may  be  assisted 
b}'-  the  right  hand  from  without.  It  is  a  question  with  many  ac- 
coucheurs which  part  of  the  inferior  extremities  should  be  seized 
and  brought  down.  Some  recommend  us  to  seize  both  feet,  others 
prefer  one  only,  while  some  advise  the  seizure  of  one  or  both  knees. 
In  a  simple  case  of  turning,  before  the  escape  of  the  waters,  it  does 
not  matter  much  which  of  these  plans  is  followed,  since  version  is 
accomplished  with  the  greatest  ease  by  any  one  of  them.  The  seizure 
of  the  knee,  however,  instead  of  the  feet,  offers  certain  advantages 
which  should  not  be  overlooked.  It  is  generally  more  accessible, 
affords  a  better  hold  (the  fingers  being  inserted  in  the  flexure  of  the 
ham),  and,  being  nearer  the  spine,  traction  acts  more  directly  on  the 
body  of  the  child.     Any  danger  of  mistaking  the  knee  for  the  elbow 


TURNING, 


461 


may  be  obviated  by  remembering  the  simple   rule  that  the  salient 
angle  of  the  former  looks  towards  the  head  of  the  child,  of  the  latter 


Fig.  148. 


Drawing  down  of  the  Feet  and  Completion  of  Version, 

towards  its  feet.  Certain  advantages  may  also  be  gained  by  bring- 
ing down  one  foot  or  knee  only,  instead  of  both.  When  one  inferior 
extremity  remains  flexed  on  the  body  of  the  child,  the  part  which 
has  to  pass  through  the  os  is  larger  than  when  both  legs  are  drawn 
down,  and  consequently  the  os  is  more  perfectly  dilated,  and  less 
difficulty  is  likely  to  be  experienced  in  the  delivery  of  the  rest  of  the 
body,  so  that  the  risk  to  the  child  is  materially  diminished. 

Choice  of  Leg  to  he  brought  down  in  Transverse  Presentations. — 
Simpson,  whose  views  have  been  adopted  by  Barnes  and  other  writers, 
recommends  the  seizing  if  possible,  in  arm  presentations,  of  the  knee 
farthest  from  and  opposite  to  the  presenting  arm,  as  by  this  means 
the  body  is  turned  round  on  its  longitudinal  axis,  and  the  presenting 
arm  and  shoulder  more  easily  withdrawn  from  the  os.  Dr.  Galabin 
has  carefully  investigated  this  point  in  a  recent  paper,^  and  contends 
that  there  is  a  greater  mechanical  advantage  in  seizing  the  leg  which 
is  nearest  to,  and  on  the  same  side  as,  the  presenting  arm,  and  this, 
moreover,  is  generally  more  readily  done. 


'  Obst.  Trans.,  vol.  xix.  1877. 


462 


OBSTETRIC    OPERATIONS, 


Management  of  the  Case  after  Version. — As  soon  as  the  head  has 
reached  the  fundus,  and  the  lower  extremity  is  brought  through  the 
OS,  the  case  is  converted  into  a  foot  or  knee  presentation,  and  it  comes 
to  be  a  question  whether  dehvery  should  now  be  left  to  nature  or 
terminated  by  art.  This  must  depend  to  a  certain  extent  on  the  case 
itself,  and  on  the  cause  which  necessitated  version,  but  generally,  it 
will  be  advisable  to  finish  delivery  without  unnecessary  delay.  To 
accomplish  this,  downward  traction  is  made  during  the  pains,  and 
desisted  from  in  the  intervals  (Fig.    149).     As  the  umbilical  cord 


Fig.  149. 


Showing  the  Completion  of  Version.     (After  Barnes.) 

appears,  a  loop  should  be  drawn  down  ;  and  if  the  hands  be  above 
the  head,  they  must  be  disengaged  and  brought  over  the  face,  in  the 
same  manner  as  in  an  ordinary  footling  presentation.  The  manage- 
ment of  the  head,  after  it  descends  into  the  cavity  of  the  pelvis,  must 
also  be  conducted  as  in  labors  of  that  description. 

Turning  in  Placenta  Prse.via. — In  cases  of  placenta  previa  the  os 
will,  as  a  rule,  be  more  easily  dilatable  than  in  transverse  presenta- 
tions. Hicks's  method  offers  the  great  advantage  of  enabling  us  to 
perform  version  much  sooner  than  was  formerly  possible,  since  it 
only  requires  the  introduction  of  one  or  two  fingers  into  the  os  uteri. 
Should  we  not  succeed  by  it,  and  the  state  of  the  patient  indicates 
that  delivery  is  necessary,  we  have  at  our  command,  in  the  fluid 
dilators,  a  means  of  artificially  dilating  the  os  uteri  which  can  be 


TURNING. 


463 


employed  with  ease  and  safety.  If  we  have  to  do  with  a  case  of 
entire  placental  presentation,  the  hand  should  be  passed  at  that  point 
where  the  placenta  seems  to  be  least  attached.  This  will  always  be 
better  than  attempting  to  perforate  its  substance,  a  measure  some- 
times recommended,  but  more  easily  performed  in  theory  than  in 
practice.  If  the  placenta  only  partially  present,  the  hand  should,  of 
course,  be  inserted  at  its  free  border.  It  will  frequently  be  advisable 
not  to  hasten  delivery  after  the  feet  have  been  brought  through  the 
OS,  for  they  form  of  themselves  a  very  efficient  plug,  and  effectually 
prevent  further  loss  of  blood ;  while,  if  the  patient  be  much  ex- 
hausted, she  may  have  her  strength  recruited  by  stimulants,  etc., 
before  the  completion  of  deliver3^ 

Turning  in  Ahdomino-anterior  Positions. — In  abdomino-anterior 
positions,  in  which  the  waters  have  escaped,  and  in  which,  therefore, 
some  difficulty  may  be  reasonably  anticipated,  the  operation  is  gener- 
ally more  easily  performed  with  the  patient  on  her  back;  the  rio-ht 
hand  is  then  introduced  in  the  uterus,  and  the  left  employed  exter- 
nally (Fig.  150).     In  this  way  the  internal  hand  has  to  be  passed  a 

Fig.  150. 


Showing  the  Use  of  the  Right  Hand  in  Abdomino-anterior  Position. 

shorter  distance,  and  in  a  less  constrained  position.  The  operator 
then  sits  in  front  of  the  patient,  who  is  supported  at  the  edge  of  the 
bed  in  the  lithotomy  position  with  the  thighs  separated,  and  the  right 
hand  is  passed  up  behind  the  pubis,  and  over  the  abdomen  of  the 
child. 

Difficult  Cases  of  Arm  Presentation. — The  difficulties  of  turning 
culminate  in  those  unfavorable  cases  of  arm  presentation  in  whicli 
the  membranes  have  been  long  ruptured,  the  shoulder  and  arm 
pressed  down  into  the  pelvis,  and  the  uterus  contracted  round  the 


464  OBSTETRIC  OPERATIONS. 

body  of  the  child.  The  uterus  being  firmly  and  spasmodically  con- 
tracted, the  attempt  to  introduce  the  hand  often  only  makes  matters 
worse,  by  inducing  more  frequent  and  stronger  pains.  Even  if  the 
hand  and  arm  be  successfully  passed,  much  difficulty  is  often  ex- 
perienced in  causing  the  body  of  the  child  to  rotate  ;  for  we  have  no 
longer  the  fluid  medium  present  in  which  it  floated  and  moved  with 
ease,  and  the  arm  of  the  operator  may  be  so  cramped  and  pained, 
by  the  pressure  of  the  uterine  walls,  as  to  be  rendered  almost  power- 
less. The  risk  of  laceration  is  also  greatly  increased,  and  the  care 
necessary  to  avoid  so  serious  an  accident  adds  much  to  the  difficulty 
of  the  operation. 

Value  of  Ansesthesia  in  Relaxing  the  Uterus. — In  these  perplexing 
cases  various  expedients  have  been  tried  to  cause  relaxation  of  the 
spasmodically  contracted  uterine  fibres,  such  as  copious  venesection 
in  the  erect  attitude  until  fainting  is  induced,  warm  baths,  tartar 
emetic,  and  similar  depressing  agents.  None  of  these,  however,  are 
so  useful  as  the  free  administration  of  chloroform,  which  has  practi- 
cally superseded  them  all,  and  often  answers  most  effectually  when 
given  to  its  fall  surgical  extent. 

Mode  of  Procedure. — -The  hand  must  be  introduced  with  the  pre- 
cautions already  described.  If  the  arm  be  completely  protruded 
into  the  vagina,  we  should  pass  the  hand  along  it  as  a  guide,  and  its 
palmar  surface  will  at  once  indicate  the  position  of  the  child's  abdo- 
men. No  advantage  is  gained  by  amputation,  as  is  sometimes  recom- 
mended. When  the  os  is  reached,  the  I'eal  difficulties  of  the  operation 
commence,  and,  if  the  shoulder  be  firmly  pressed  down  into  the  brim 
of  the  pelvis,  it  may  not  be  easy  to  insinuate  the  hand  past  it.  It  is 
allowable  to  repress  the  presenting  part  a  little,  but  with  extreme 
caution,  for  fear  of  injuring  the  contracted  uterine  parietes.  It  is 
better  to  insinuate  the  hand  past  the  obstruction,  which  can  generally 
be  done  by  patient  and  cautious  endeavors.  Having  succeeded  in 
passing  the  shoulder,  the  hand  is  to  be  pressed  forward  in  the  intervals, 
being  kept  perfectly  flat  and  still  on  the  body  of  the  foetus  when  the 
pains  come  on.  It  is  much  safer  to  press  on  it  than  on  the  uterine 
walls,  which  might  readily  be  lacerated  by  the  projecting  knuckles. 
When  the  hand  has  advanced  sufficiently  far,  it  will  be  better,  for 
the  reasons  already  mentioned,  to  seize  and  bring  down  one  knee 
only. 

Management  of  Cases  in  tvhich  the  Foot  is  brought  down  hut  the  Foetus 
v:ill  not  Revolve. — Even  when  the  foot  has  been  seized  and  brought 
through  the  os,  it  is  by  no  means  always  easy  to  make  the  child 
revolve  on  its  axis,  as  the  shoulder  is  often  so  firmly  fixed  in  the 
pelvic  brim  as  not  to  rise  towards  the  fundus.  Some  assistance  may 
be  derived  from  pushing  the  head  upwards  from  without,  which,  of 
course,  Avould  raise  the  shoulder  along  with  it.  If  this  should  fail, 
me  may  effect  our  object  by  passing  a  noose  of  tape  or  wire  ribbon 
round  the  limb,  by  which  traction  is  made  downwards  and  back- 
wards ;  at  the  same  time,  the  other  hand  is  passed  into  the  vagina  to 
displace  the  shoulder  and  push  it  out  of  the  brim.  It  is  evident  that 
this  cannot  be  done  as  long  as  the  limb  is  held  by  the  left  hand,  as 


THE    FORCEPS.  465 

there  is  no  room  for  both  hands  to  pass  into  the  vagina  at  the  same 
time.  By  this  manoeuvre  version  may  be  often  completed,  wlien  the 
foetus  cannot  be  turned  in  the  ordinary  way.  Various  instruments 
have  been  invented,  both  for  passing  a  lac  round  the  child's  limb,  and 
for  repressing  the  shoulder,  but  none  of  them  can  compete,  either  in 
facility  of  use  or  safety,  with  the  hand  of  the  accoucheur. 

Should  all  attempts  at  version  fail,  no  resource  is  left  but  the 
mutilation  of  the  child,  either  by  evisceration  or  decapitation.  This 
extreme  measure  is,  foi'tunately,  seldom  necessary,  as  with  due  care 
version  may  generally  be  effected,  even  under  the  most  unfavorable 
circumstances. 


CIIAPTEE    III. 

THE  FOECEPS. 

Of  all  obstetric  operations  the  most  important,  because  the  most 
truly  conservative  both  to  the  mother  and  child,  is  the  application 
of  the  forceps.  In  modern  midwifery  the  use  of  the  instrument  is 
much  extended,  and  it  is  now  applied  by  some  of  our  most  expe- 
rienced accoucheurs  with  a  frequency  which  older  practitioners  would 
have  strongly  reprobated.  That  the  injudicious  and  unskilful  use  of 
the  forceps  is  capable  of  doing  much  harm,  no  one  will  for  a  moment 
deny.  This,  however,  is  not  a  reason  for  rejecting  the  recommenda- 
tion of  those  Avho  advise  a  more  frequent  resort  to  the  operation,  but 
rather  for  urging  on  the  practitioner  the  necessity  of  carefully  study- 
ing the  manner  of  performing  it,  and  of  making  himself  familiar  with 
the  cases  in  which  it  is  easy  or  the  reverse.  Nothing  but  practice — ■ 
at  first  on  the  dummy,  and  afterwards  in  actual  cases — can  impart 
the  operative  dexterity  which  it  should  be  the  aim  of  every  obstetri- 
cian to  acquire,  and  without  which  there  can  be  no  assurance  of  his 
doing  his  duty  to  his  patient  efficiently. 

Description  of  the  Instrii-ment. — The  forceps  may  best  be  described 
as  a  pair  of  artificial  hands,  by  which  the  foetal  head  may  be  grasped 
and  drawn  through  the  maternal  passages  by  a  vis  a  f route,  when 
the  vis  a  tercjo  is  deficient.  This  description  will  impress  on  the  mind 
the  important  action  of  the  instrument  as  a  tractor,  to  which  all  its 
other  powers  arc  subservient.  The  forceps  consists  of  two  separate 
blades  of  a  curved  form,  adapted  to  fit  the  child's  head ;  a  lock  by 
which  the  blades  are  united  after  introduction ;  and  handles  which 
are  grasped  by  the  operator,  and  by  means  of  which  traction  is  made. 
It  would  be  a  wearisome  and  unsatisfactory  task  to  dwell  on  all  the 
modifications  of  the  instrument  which  have  been  made,  which  are  so 
numerous  as  to  make  it  almost  appear  as  if  no  one  could  practise 


466 


OBSTETRIC    OPERATIONS. 


Fig.  151. 


midwifery  with    the  least  pretension  to  eminence,   unless    he    has 
attached  his  name  to  a  new  variety  of  forceps. 

The  Short  Forceps. — The  original  instrument,  invented  by  the 
Chamberlens,  may  be  looked  upon  as  the  type  of  the  short  straight 
forceps,  which  has  been  more  employed  than  any  other,  and  which, 
perhaps,  finds  its  best  representative  in  the  short  forceps  of  Denman 
(Fig.  151).     Indeed  the  only  essential  difference  between  the  two  is 

the  lock  of  the  latter,  originally  in- 
vented by  Smellie,  which  is  so  excellent 
that  it  has  been  adopted  in  all  British 
forceps;  and  which,  for  facility  of  junc- 
ture, is  much  superior  to  either  the 
French  pivot,  or  the  German  lock, 
while  for  firmness  it  is,  for  all  practical 
purposes,  as  good  as  either.  In  this 
instrument  the  blades  are  7,  the  handles 
4|  inches  in  length  ;  the  extremities  of 
the  blades  are  exactly  1  inch  apart, 
and  the  space  between  them,  at  their 
widest  part,  is  2|  inches.  The  blades 
measure  If  inches  at  their  greatest 
breadth,  and  spring  with  a  regular 
sweep  directly  from  the  lock,  there 
being  no  shank.  The  blades  are  formed 
of  the  best  and  most  highly  tempered 
steel,  to  resist  the  strain  to  which  they 
are  occasionally  subjected,  and  they  are 
smooth  and  rounded  on  their  inner  sur- 
face, to  obviate  the  risk  of  injury  to 
the  scalp  of  the  child. 

Advantages  claimed  for  this  Form  of 
Instrument.  —  The  special  advantage 
claimed  for  this  form  of  instrument  is, 
that,  the  two  halves  being  precisely 
similar,  no  care  or  forethought  is  required  on  the  part  of  the  practi- 
tioner as  to  which  blade  should  be  introduced  uppermost — an  ad- 
vantage of  no  great  value,  since  no  one  should  undertake  a  case  of 
forceps  delivery  who  has  not  sufficient  knowledge  of  the  operation, 
and  presence  of  mind  enough  to  obviate  any  risk  from  the  intro- 
duction of  the  wrong  blade  first.  On  account  of  its  shortness,  and 
the  want  of  the  second  or  pelvic  curve,  it  is  only  adapted  for  cases 
in  which  the  head  is  low  down  in  the  pelvis,  or  actually  resting  on 
the  perineum. 

The  Pelvic  Curve^  its  Advantages. — The  question  of  the  second  or 
pelvic  curve  is  one  on  which  there  is  much  difference  of  opinion. 
The  forceps  we  are  now  considering,  and  the  many  modifications 
formed  on  the  same  plan,  is  constructed  solely  with  reference  to  its 
grasp  on  the  child's  head,  and  Avithout  regard  to  the  axes  of  the 
maternal  passages.  Consequently  were  we  to  introduce  it  when  the 
head  was  at  the  upper  part  of  the  pelvis,  we  could  not  fail  to  expose 


Denman'g  Short  Forceps. 


THE    FORCEPS. 


467 


Fig.  152. 


the  soft  parts  to  the  risk  of  contusion,  and  (in  consequence  of  the 
necessity  of  drawing  more  directly  backwards)  unduly  stretch  and 
even  lacerate  the  perineum.  Hence  it  is  now  admitted  by  obstetri- 
cians, with  few  exceptions,  that  the  second  curve  is  essential  before 
the  complete  descent  of  tlie  head,  although  it  is  not  absolutely  so 
after  this  has  taken  place.  Tiie  only  circumstances  under  which  a 
straight  blade  can  possess  any  superiority  are  in  certain  cases  of 
occipito-posterior  position,  in  which  it  is  found  necessary  to  rotate 
the  head  round  a  large  extent  of  the  pelvis,  when  the  circular  sweep 
of  a  strongly-curved  instrument  might  prove  injurious.  Such  cases, 
however,  are  of  rare  occurrence,  and  need  in  no  way  influence  the 
general  employment  of  the  pelvic  curve. 

Zeiyler''s  Forceps. — Tlie  short  forceps,  usually  employed  in  Scot- 
land, is  the  invention  of  the  late  Zeigler  (Fig.  152),^  and  is  useful 
from  the  facility  with  which  the  blades  may  be 
introduced  in  accurate  apposition  to  each  other,  a 
point  which  in  practice  is  of  no  little  value.  In 
general  size  and  appearance  it  closely  resembles 
Denman's  forceps,  but  the  fenestrum  of  the  lower 
blade  is  continued  down  to  the  handle.  In  intro- 
ducing, the  lower  blade  is  slipped  over  the  handle 
of  the  other  blade  already  in  situ^  and  thus  it  is 
guided  with  great  certainty  into  a  proper  position, 
locking  itself  as  it  passes  on.  This  instrument  has 
the  disadvantage  of  not  having  the  second  curve, 
but  the  facility  of  introduction  has  rendered  it  a 
great  favorite  with  many  who  have  been  in  the 
habit  of  employing  it. 

The  Long  Forceps. — For  cases  in  which  the  head 
is  not  on  the  perineum,  or  at  least  not  quite  low  in 
the  pelvis,  a  longer  instrument  is  essential.  To 
meet  this  indication  Smellie  invented  the  long 
forceps,  which,  like  the  shorter  instrument,  has 
been  very  variously  modified.  The  most  perfect  instrument  of  the 
kind  employed  in  this  country  is  that  known  as  Simpson's  forceps 
(Fig.  153),  which  combines  many  excellent  points  selected  from  the 
forceps  of  various  obstetricians,  as  well  as  some  original  additions, 
and  which,  as  a  whole,  has  never  been  surpassed.  The  curved  portions 
of  the  blades  are  6J  inches  long,  the  fenestrum  measuring  1\  at  its 
widest  part.  The  extremities  of  the  blades  are  1  inch  asunder  when 
the  handles  are  closed,  and  3  inches  at  their  widest  part.  The  object 
of  this  somewhat  unusual  width  is  to  lessen  the  compressing  power 
of  the  instrument,  without  in  any  way  interfering  with  its  action  as 
a  tractor.  The  pelvic  curve  is  less  than  in  most  long  forceps,  so  as 
to  admit  of  the  rotation  of  the  head  when  necessary,  without  the  risk 
of  injuring  the  maternal  structures.  Between  the  curve  of  the  blade 
and  the  lock  is  a  straight  portion  or  shank,  measuring  2f  inches, 
which,  before  joining  the  handle,  is  bent  at  right  angles  into  a  knee. 


Zeiprler's  Forceps. 


f  It  lias  been  marie  here,  but  is  not  regarded  with  any  favor. — Ed.] 


468 


OBSTETRIC    OPERATIONS. 


Fig.  153. 


This  shank  is  a  useful  addition  to  all  forceps,  and  is  essential  in  the 
long  forceps  to  insure  the  junction  of  the  blades  beyond  the  parts  of 
the  mother,  which  might  otherwise  be  caught  in  the  lock  and  injured. 
The  knees  serve  the  purpose  of  preventing  the  blades  from  slipping 
from  each  other  after  they  have  been  united.     They  also  admit  of 

one  finger  being  introduced  above 
the  lock,  and  used  as  an  aid  in 
traction ;  a  provision  which  is  made 
in  some  other  varieties  of  long 
forceps  by  a  semicircular  bend  in 
each  shank.  The  handles  which 
in  most  British  forceps  are  too 
small  and  smooth  to  afford  a  firm 
grasp,  are  serrated  at  the  edge,  and 
flattened  from  before  backwards, 
so  as  to  fit  the  closed  fist  more 
accurately.  At  their  extremities, 
near  the  lock,  there  are  a  pair  of 
projecting  rests,  over  which  the 
fore  and  middle  fingers  may  be 
passed  in  traction,  and  which 
greatly  increase  our  power  over 
the  instrument.  Although  this, 
and  other  varieties  of  the  long 
forceps,  are  specially  constructed 
for  application  when  the  head  is 
high  in  the  pelvis,  it  answers  quite 
as  well  as  the  short  forceps — in- 
deed, in  most  respects  better — • 
when  the  head  has  descended  low 
down.  It  is  a  decided  advantage 
for  the  practitioner  to  habituate 
himself  to  the  use  of  one  instru- 
ment, with  the  application  and 
power  of  which  he  becomes  thoroughly  familiar.  It  is  a  mere  waste 
of  space  and  money  for  him  to  incumber  himself  with  a  number  of 
instruments  of  various  shapes  and  sizes,  and  he  may  be  sure  that  a 
good  pair  of  long  forceps,  such  as  Simpson's,  will  be  suitable  for 
every  emergency,  and  in  any  position  of  the  head. 

Disadvantages  of  a  Weak  Instrument. — The  chief  argument 
against  the  use  of  such  an  instrument  in  simple  cases  is  its  great 
power.  This,  however,  is  entirely  based  on  a  misconception.  The 
existence  of  power  does  not  involve  its  use,  and  the  stronger  instru- 
ment can  be  employed  with  quite  as  much  delicacy  and  gentleness  as 
the  weaker.  The  remarks  of  Dr.  Hodge^  on  this  point  are  extremely 
apposite,  and  are  well  worthy  of  quotation.  He  says,  "  Certainlj^  no 
man  ought  to  apply  the  forceps  who  has  not  sufficient  discretion  to 
use  no  more  force  than  is  absolutely  requisite  for  safe  delivery ;  if, 


Simpson's  Forceps. 


System  of  Obstetrics,  p.  242. 


THE    FORCEPS. 


469 


therefore,  there  is  more  power  at  command,  he  is  not  obliged  to  use 
if  while,  oil  the  contrar}^,  if  much  power  be  demanded,  he  can, 
within  the  bounds  of  prudence,  exercise  it  by  the  long  forceps,  but 
with  the  short  forceps  his  efforts  might  be  unavailing;  moreover,  in 
cases  of  difficulty,  the  short  forceps  being  used,  the  practitioner 
would  be  forced  to  make  great  muscular  efforts ;  while  with  the  long 
forceps,  owing  to  the  great  leverage,  such  effort  Avill  be  compara- 
tively trifling,  and,  of  course,  the  whole  force  demanded  can  be  much 
more  delicately,  and  at  the  same  time  efficiently  applied,  and  with 
more  safety  to  the  tissues  of  the  child  and  its  parent." 

Continental  Forceps. — The  forceps  usually  employed  on  the  Con- 
tinent, and  in  America,  differ  considerably,  both  in  appearance  and 
construction,  from  those  in  use  in  this  country.  As  a  rule  it  is  a 
larger  and  more  powerful  instrument,  joined  by  a  pivot  or  button 
joint,  and  it  always  possesses  the  second  or  pelvic  curve.  Of  late 
years  Simpson's  forceps  has  been  much  employed  in  some  parts 
of  Germany.  The  chief  objection  to 
the  Continental   instruments  is  their  Fig.  154. 

cumbrousness.  This  is  chiefly  in  the 
handles,  which  in  many  of  them  are 
forged  in  a  piece  with  the  blades,  the 
part  introduced  within  the  maternal 
structures  not  being  materially  differ- 
ent from  the  corresponding  part  of  the 
English  instrument. 

The  forceps  invented  by  Professor 
Tarnier  (Fig.  154)  have  recently  at- 
tracted considerable  attention.  In  this 
instrument  traction  is  not  made  on  the 
handles  by  which  the  blades  are  intro- 
duced, as  in  ordinary  forceps,  but  on  a 
supplementary  handle  (a)  subsequently 
attached  to  the  blades  near  the  lower 
opening  of  their  fenestrce  {h).  The 
object  claimed  for  this  arrangement  is 

that  less  force  is  required  in  traction,  Tamier's  Forceps, 

which    can   always   be   made    in   the 

proper  axis  of  the  pelvis ;  that  the  blades  are  not  likely  to  slip  ;  and 
that  rotation  of  the  head  is  not  interfered  with.  The  instrument, 
however,  is  much  more  complex  than  that  usually  emploj^ed  in  this 
country,  and  does  not  seem  to  possess  sufficient  advantages  to  coun- 
terbalance this  defect.^ 

Action  of  the  Instrument. — The  forceps  is  generally  said  to  act  in 
three  different  ways  : — ■ 

1st.  As  a  tractor. 

2d.  As  a  lever. 

3d.  As  a  compressor. 


['  Professor  Tarnier  has  adopted,  in  this  instrument,  the  hlades  of  Davis.  It  has 
been  much  simplified  recently,  by  Dr.  Richard  A.  Cleemann,  of  Philadelphia,  by  taking 
away  the  long  curve  of  the  handles,  dispensing  with  the  tongue,  and  bending  for- 
ward the  shanks. — Ed.] 


470  OBSTETRIC  OPERATIONS, 

The  Chief  Use  of  the  Force'ps  as  a  Tractor. — It  is  more  especially  as 
a  tractor  that  the  instrument  is  of  value,  and  it  is  used  with  the  great- 
est advantage  when  it  is  employed  merely  to  supplement  the  action 
of  the  uterus,  which  is  insufficient  of  itself  to  effect  delivery,  or^  when, 
from  some  complication,  it  is  necessary  to  complete  labor  with  greater 
rapidity  than  can  be  accomplished  by  the  unaided  powers  of  nature. 
In  most  cases  traction  alone  is  sufficient ;  but,  in  order  that  it  may 
act  satisfactorily,  and  that  the  instrument  may  not  slip,  a  proper  con- 
struction of  the  forceps,  and  a  sufficient  curvature  of  the  blades,  are 
essential.  The  want  of  these  is  the  radical  fault  of  many  of  the 
short,  straight  instruments  in  common  use,  which  have  a  tendency  to 
slip  during  our  efforts  at  extraction. 

As  a  Lever. — The  forceps  acts  also  as  a  lever,  but  this  action  has 
been  greatly  exaggerated.  It  is  generally  described  as  a  lever  of  the 
first  class,  the  power  being  at  the  handles,  the  fulcrum  at  the  lock, 
and  the  weight  at  the  extremities.  There  may  possibly  be  some 
leverage  power  of  this  kind  when  the  instrument  is  first  introduced, 
and  the  handles  held  so  loosely  that  one  blade  is  able  to  work  on  the 
other.  But,  as  ordinarily  used,  the  handles  are  held  with  a  suffi- 
ciently firm  grasp  to  prevent  this  movement,  and  then  the  two  blades 
practically  form  a  single  instrument. 

Galabin,  who  has  studied  this  subject  in  detail,  points  out^  that: 
"1.  The  lever  is  formed  by  both  blades  of  the  forceps  and  the  foetal 
head  united  in  one  immovable  mass.  As  soon  as  the  blades  begin 
to  slip  over  the  head,  the  lever  is  decomposed,  and  the  swaying  move- 
ment ceases  to  have  any  mechanical  advantage.  2.  The  power  is 
applied  to  the  handles  in  a  slanting  direction.  The  resistance  or 
weight  does  not  act  at  a  point  either  between  the  former  and  the 
fulcrum,  or  beyond  the  fulcrum,  but  at  a  point  in  a  plane  nearly  at 
right  angles  to  the  line  joining  these  two  points;  and  its  direction  is 
a  line  perpendicular  to  that  plane  of  the  pelvis  in  which  the  greatest 
section  of  the  head  is  engaged,  that  is  to  say,  in  the  case  of  straight 
forceps,  nearly  parallel  to  the  handles.  The  lever  formed  does  not, 
therefore,  strictly  speaking,  belong  to  any  one  of  the  three  orders 
into  which  levers  are  commonly  divided.  3.  The  fulcrum  is  fixed 
partly  by  friction,  partly  by  the  combination  of  traction  with  oscil- 
latory movement — in  other  words,  by  the  power  being  directed  in 
great  measure  downwards,  and  only  slightly  to  one  side." 

He  further  shows  that  the  pendulum  motion  of  the  forceps  is  super- 
fluous in  all  ordinary  forceps  operations,  in  which  traction  alone  is 
amply  sufficient  for  delivery;  but  that  when  the  head  is  impacted, 
and  great  force  is  required  for  its  extraction,  a  mechanical  advantage 
may  be  gained  from  having  recourse  to  an  oscillatory  movement, 
which  should,  however,  be  very  limited,  and  only  continued  if  found 
to  effect  distinct  advance  of  the  head. 

As  a  Compressor. — Eegarding  the  compressive  power  of  the  instru- 
ment there  has  been  much  difference  of  opinion.     There  is  no  doubt 

'  (xalabin,  "Action  of  Midwifery  Forceps  as  a  Lever,"  Obstetrical  Journal, 
November,  1876. 


THE    FORCEPS.  471 

that  the  forceps,  especially  some  of  the  foreign  instruments  in  which 
the  points  nearly  approach  each  other,  is  capable  of  exerting  con- 
siderable compression  on  the  head.  It  is,  however,  extremely  prob- 
lematical if  this  action  be  of  real  value.  It  is  to  be  borne  in  mind 
that  in  cases  of  protracted  labor  the  head  has  been  already  moulded 
and  compressed,  and  the  bones  have  been  made  to  overlap  each  other 
to  their  utmost  extent,  by  the  sides  of  the  pelvis;  we  can  scarcely, 
therefore,  expect  to  diminish  the  head  much  more  by  the  forceps, 
without  employing  an  amount  of  force  that  will  seriously  endanger 
the  life  of  the  child.  It  is  in  cases  of  disproportion  between  the 
head  and  the  pelvis,  depending  on  slight  antero- posterior  contraction 
of  the  pelvic  brim,  that  diminution  of  the  child's  head  by  compres- 
sion would  be  most  useful.  Then,  however,  the  pressure  of  the 
forceps  is  exerted  on  that  portion  of  the  head  which  lies  in  the  most 
roomy  diameter  of  the  pelvis,  where  there  is  no  want  of  space.  If 
this  pressure  do  not  increase  the  opposite  diameter,  which  is  in  appo- 
sition to  the  narrower  portion  of  the  pelvis,  it  can  at  least  do  nothing 
towards  lessening  it;  and  diminution  of  any  other  part  of  the  child's 
head  is  not  required. 

Dynamical  Action  of  the  Forcejjs. — The  mere  introduction  of  the 
forceps  sometimes  excites  increased  uterine  action,  through  the  reflex 
irritation  induced  by  the  presence  of  a  foreign  body  in  the  vagina. 
This  has  been  called  the  dynamical  action  of  the  forceps ;  but  it  can- 
not be  looked  upon  in  any  other  light  than  that  of  an  occasional 
accidental  result. 

The  circumstances  indicating  the  use  of  the  forceps  have  been 
separately  considered  elsewhere,  and  to  recapitulate  them  here  would 
only  lead  to  needless  repetition.  I  shall  therefore  now  merely  de- 
scribe tiie  mode  of  using  the  instrument. 

Difference  hetiveen.  the  High  and  Low  Operations. — Before  doing  so 
it  is  well  to  repeat  what  has  already  been  said  as  to  the  difference 
between  what  may  be  termed  the  high  and  low  forceps  operations. 
The  application  of  the  instrument,  when  the  head  is  low  in  the  pelvis, 
is  extremely  simple;  and  when  there  is  no  disproportion  between  the 
head  and  the  pelvis,  and  some  slight  traction  is  alone  required  to 
supplement  deficient  expulsive  power,  the  operation,  in  the  hands  of 
any  ordinarily  well-instructed  practitioner,  ought  to  be  perfectly  safe 
both  to  the  mother  and  child.  It  is  very  different  when  the  head  is 
arrested  at  the  brim,  or  high  in  the  pelvis.  Then  the  application  of 
the  forceps  is  an  operation  requiring  much  dexterity  for  its  proper 
performance,  and  must  never  be  undertaken  without  anxious  con- 
sideration. It  is  because  these  two  classes  of  operations  have  been 
confused  that  the  use  of  the  instrument  is  regarded  by  many  with 
such  unreasonable  dread. 

Preliminary  Considerations. — Before  attempting  to  introduce  the 
forceps,  there  are  several  points  to  which  attention  should  be  di- 
rected : — 

1st.  The  membranes  must,  of  course,  be  ruptured. 

2dly.  For  the  safe  and  easy  application  of  the  instrument,  it  is 
also  advisable  that  the  os  should  be  fully  dilated,  and  the  cervix  re- 


472  OBSTETRIC  OPERATIONS. 

tracted  over  the  head.  Still,  these  two  points  cannot  be  regarded,  as 
many  have  laid  down,  as  being  sine  qua  non.  Indeed  we  are  often 
compelled  to  use  the  instrument  when,  although  the  os  is  fully  dilated, 
the  rim  of  the  cervix  can  be  felt  at  some  point  of  the  contour  of  the 
head,  especially  in  cases  in  which  the  anterior  lip  is  jammed  between 
the  head  and  the  pubis.  Provided  due  care  be  taken  to  guard  the 
cervical  rim  with  the  fingers  of  one  hand,  as  the  instrument  is 
slipped  past  it,  there  need  be  no  fear  of  injury  from  this  cause.  If 
the  OS  be  not  fully  dilated,  but  is  sufficiently  open  to  admit  of  the 
passage  of  the  forceps,  the  operation,  under  urgent  circumstances, 
may  be  quite  justifiable,  but  it  must  necessarily  be  a  somewhat 
anxious  one. 

3dly.  The  position  of  the  head  should  be  accuratel}^  ascertained 
by  means  of  the  sutures  and  fontanelles.  Unless  this  be  done,  the 
operation  will  always  be  hap-hazard  and  unsatisfactory,  as  the  prac- 
titioner can  never  be  in  possession  of  accurate  knowledge  of  the  pro- 
gress of  the  case.  It  may  be  that  the  occiput  is  directed  backwards; 
and,  although  that  does  not  contra-indicate  the  application  of  the 
forceps,  it  involves  special  precautions  being  taken. 

•±thly.  The  bladder  and  bowels  should  be  emptied. 

Questio7i  of  Administering  Ansesthetics. — Before  proceeding  to  ope- 
rate, the  question  of  anaesthesia  will  arise.  In  any  case  likely  to  be 
difficult  it  is  of  the  greatest  assistance  to  have  the  patient  completely 
under  the  influence  of  an  anaesthetic  to  the  surgical  degree,  so  as  to 
have  her  as  still  as  possible  ;  but,  whenever  this  is  deemed  necessary, 
another  practitioner  should  undertake  the  responsibility  of  the  admin- 
istration. In  simple  cases  I  believe  it  is  better  to  dispense  with  anses- 
thetics altogether,  partly  because  they  are  apt  to  stop  what  pains 
there  are,  which  is  in  itself  a  disadvantage,  but  chiefly  because,  under 
partial  anaesthesia,  the  patient  loses  her  self-control,  is  restless,  and 
twists  herself  into  awkward  positions,  which  give  rise  to  the  utmost 
difficulty  and  inconvenience  in  the  use  of  the  instrument.  Moreover, 
if  no  anaesthetic  be  given,  the  patient  can  assist  the  operator  by 
placing  herself  in  the  most  convenient  attitude. 

Descrij)tion  of  the  Operation. — In  describing  the  method  of  apply- 
ing the  forceps,  I  shall  assume  that  we  have  to  do  with  the  simpler 
variety  of  the  operation,  when  the  head  is  low  in  the  pelvis.  Sub- 
sequently I  shall  point  out  the  peculiarities  of  the  high  operation. 

Position  of  the  Patient. — As  to  the  position  of  the  patient,  I  believe 
there  can  be  no  doubt  of  the  superiority  of  that  which  is  usually 
adopted  in  this  country.  On  the  Continent  and  in  America  the  for- 
ceps is  always  employed  with  the  patient  lying  on  her  back,  a  posi- 
tion involving  much  needless  exposure  of  the  person,  and  requiring 
more  assistance  from  others.  In  certain  cases  of  unusual  difficulty 
the  position  on  the  back  is  of  unquestionable  utility,  but  we  may,  at 
least,  commence  the  operation  in  the  usual  way,  and  subsequently 
turn  the  patient  on  her  back  if  desirable. 

Importance  of  a.  Suitahle  Position. — Much  of  the  facility  with  which 
the  blades  are  introduced  depends  on  the  patient's  being  properly 
placed.    Hence,  although  it  gives  rise  to  a  little  more  trouble  at  first, 


THE    FORCEPS 


473 


I  believe  that  it  is  always  best  to  pay  particular  attention  to  this 
point,  whether  the  high  or  low  forceps  operation  be  about  to  be  per- 
formed. Tlie  patient  should  be  brought  quite  to  the  side  of  the  bed, 
with  her  nates  parallel  to,  and  projecting  somewhat  over  its  edge. 
The  body  should  lie  almost  directly  across  the  bed,  and  nearly  at 
right  angles  to  the  hips,  with  the  knees  raised  towards  the  abdomen 

Fig.  155. 


Position  of  Patient  for  Forceps  Delivery  and  Mode  of  Introducing  Lower  Blade. 


(Fig.  155).  In  this  way  there  is  no  risk  of  the  handle  of  the  upper 
blade,  when  depressed  in  introduction,  coming  in  contact  with  the 
bed. 

The  blades  should  be  warmed  in  tepid  water,  lubricated  with  cold 
cream  or  carbolic  oil,  and  placed  ready  to  hand. 

These  preliminaries  having  been  attended  to,  we  proceed  to  the  in- 
troduction of  the  blades,  sitting  by  the  side  of  the  bed,  opposite  the 
nates  of  the  patient. 

Direction  in  ivhich  the  Blades  are  to  he  Introduced. — -The  important 
question  now  arises,  in  what  direction  are  the  blades  to  be  passed? 
The  almost  universal  rule  in  our  standard  works  is,  that  they  must 
be  passed  as  nearly  as  possible  over  the  child's  ears,  without  any  re- 
ference to  the  pelvic  diameters.  Hence,  if  the  head  have  not  made 
its  turn,  but  is  lying  in  one  oblique  diameter,  the  blades  would  re- 
quire to  be  passed  in  the  opposite  oblique  diameter ;  in  short,  the 
position  of  the  forceps,  as  regards  the  pelvis,  must  vary  according 
to  the  position  of  the  head.  Some  have  even  laid  down  the  rule, 
that  the  forceps  is  contra-indicated  unless  an  ear  can  be  felt ;  a  rule 
that  would  very  seriously  limit  its  application,  as  in  many  cases  in 
which  it  is  urgently  required  it  is  a  matter  of  great  difficulty,  and 
even  impossibility,  to  feel  the  ear  at  all.  It  is  admitted  that  in  the 
high  forceps  operation  the  blades  must  be  introduced  in  the  trans- 
31 


474  OBSTETRIC  OPERATIONS. 

verse  diameter  of  tlie  pelvis,  without  relation  to  the  position  of  the 
head.  On  the  Continent  it  is  generally  recommended  that  this  rule 
should  be  applied  to  all  cases  of  forceps  delivery  alike,  whether  the 
head  be  higli  or  low,  and  I  have  now  for  many  years  adopted  this 
plan,  and  passed  the  blades  in  all  cases,  whatever  be  the  position  of 
the  head,  in  the  transverse  diameter  of  the  pelvis,  without  any  at- 
tempt to  pass  them  over  the  bi-parietal  diameter  of  the  child's  head. 
Dr.  Barnes  points  out  with  great  force  that,  do  what  we  will,  and 
attempt  as  we  may,  to  pass  the  blades  in  relation  to  the  child's  head, 
they  fir)d  their  way  to  the  sides  of  the  pelvis,  and  that  the  marks  of 
the  fenestra  on  the  head  always  show  that  it  has  been  grasped  by  the 
brow  and  side  of  the  occiput.^  Of  the  perfect  correctness  of  this  ob- 
servation I  have  no  doubt ;  hence  it  is  a  needless  element  of  com- 
plexity to  endeavor  to  vary  the  position  of  the  blades  in  each  case, 
and  one  which  only  confuses  the  inexperienced  practitioner,  and 
renders  more  difficult  an  operation  which  should  be  simplified  as 
much  as  possible.  While,  therefore,  it  is  of  importance  that  the 
precise  position  of  the  head  should  be  ascertained  in  order  that  we 
may  have  an  intelligent  notion  of  its  progress,  I  do  not  think  that  it 
is  essential  as  a  guide  to  the  introduction  of  the  forceps. 

Method  of  Introducing  the  Lower  Blade. — As  a  rule  the  lower  blade, 
lightly  grasped  between  the  tips  of  the  index  and  middle  fingers  and 
thumb,  should  be  introduced  first.  Poised  in  this  way,  we  have  per- 
fect command  over  it,  and  can  appreciate  in  a  moment  any  obstacle 
to  its  passage.  Two  or  more  fingers  of  the  left  hand  are  introduced 
into  the  vagina,  and  by  the  side  of  the  head,  as  a  guide  ;  the  greatest 
care  must  be  taken,  if  the  cervix  be  within  reach,  that  they  are  passed 
within  it,  so  as  to  avoid  the  possibility  of  injury. 

Necessity  of  Gentleness  in  Passing  the  Instrument.- — The  handle  of 
the  instrument  has  to  be  elevated,  and  its  point  slid  gently  along  the 
palmar  surface  of  the  guiding  fingers,  nntil  it  touches  the  head  (Fig. 
155).  At  first  the  blade  should  be  inserted  in  the  axis  of  the  outlet, 
but  as  it  progresses,  the  handle  must  be  depressed  and  carried  back- 
wards. As  it  is  pushed  onwards  it  is  made  to  progress  by  a  slight 
side-to-side  motion,  and  it  is  of  the  utmost  importance  to  bear  in 
mind  that  the  greatest  gentleness  must  always  be  used.  If  any  ob- 
struction be  felt,  we  are  bound  to  withdraw  the  instrument,  partially 
or  entirely,  and  attempt  to  manoeuvre,  not  force,  the  point  past  it. 
As  the  blade  is  guided  on  in  this  way,  it  is  made  to  pass  over  the 
convexity  of  the"head,  the  point  being  always  ke];)t  lightly  in  contact 
with  it,  until  it  finally  gains  its  proper  position.  When  fully  inserted 
the  handle  is  drawn  ba'ck  towards  the  perineum,  and  given  in  charge 
to  an  assistant.  The  insertion  must  be  carried  on  only  in  the  inter- 
vals betAveen  the  pains,  and  desisted  from  during  their  occurrence ; 
otherAvise  there  would  be  a  serious  risk  of  injuring  the  soft  parts  of 
the  mother. 

Introduction  of  the  Uj^j'^er  Blade. — The  second  blade  is  passed  di- 

[1  This  is  not  tlie  case  wlien  the  forceps  used  is  made  to  adapt  itself  to  the  sides  of 
the  child's  head,  such  as  the  Wallace,  Davis,  or  Hodge  instruments. — Ed.] 


THE    FORCEPS. 


475 


rectly"  opposite  to  the  first,  and  is  generally  somewhat  more  difficult 
to  introduce,  in  consequence  of  the  space  occupied  by  the  latter.  It 
is  passed  along  two  lingers  directly  op[)osite  the  first  blade,  and  with 
exactly  the  same  precautions  as  to  direction  and  introduction  except 
that  at  first  its  handle  has  to  be  depressed  instead  of  elevated  (Fig. 
156). 

Fig.  156. 


Introductiou  of  the  Upper  Blade. 

Locldng  of  the  Handles. — The  handle  which  was  in  charge  of  the 
assistant  is  now  laid  hold  of  by  the  operator,  and  the  two  handles 
are  drawn  together.  If  the  blades  have  been  properly  introduced, 
there  should  be  no  difficulty  in  locking  ;  but,  should  we  be  unable  to 
join  them  easily,  we  must  withdraw  one  or  other,  either  partiallv  or 
entirely,  and  reintroduce  it  with  the  same  precautions  as  before.  We 
must  also  assure  ourselves  that  no  hairs,  nor  any  of  the  maternal 
structures  are  caught  in  the  lock. 

Method  of  Traction. — -When  once  the  blades  are  locked  we  may 
commence  our  efforts  at  traction.  To  do  this  we  lay  hold  of  the 
handles  with  the  right  hand,  using  only  sufficient  compression  to 
give  a  firm  grasp  of  the  head,  and  to  keep  the  blades  from  slipping. 
The  left  hand  may  be  advantageously  used  in  assisting  and  support- 
ing the  right  during  our  effiDrts  at  extraction,  and,  at  a  late  stage  of 
the  operation,  may  be  employed  in  relaxing  the  perineum  when 
stretched  by  the  head  of  the  child.  Traction  must  alwavs  be  made 
in  reference  to  the  pelvic  axes  ;  being  at  first  backwards  towards  the 
perineum  (Fig.  157),  in  the  direction  of  the  axis  of  the  brim,  and  as 
the  head  descends  and  the  vertex  protrudes  through  the  vulva,  it 
must  be  changed  to  that  of  the  outlet.  We  must  extract  only  during 
the  pains;  and,  if  these  should  be  absent,  we  must  imitate  them  by 
acting  at  intervals.  This  is  a  point  which  deserves  special  attention, 
for  there  is  no   more  common  error  than  undue  hurrv  in  delivery. 


476 


OBSTETRIC    OPERATIONS. 


The  only  valid  objection  I  know  of  against  a  more  frequent  resort 
to  the  forceps  in  lingering  labors  is,  that  the  sudden  emptying  of  the 


Fig.  157. 


Forceps  in  Position.     Traction  in  tlie  Axis  of  the  Brim,  downwards  and  baclcwards . 

uterus,  in  the  absence  of  pains,  may  predispose  to  hemorrhage ;  and 
it  cannot  be  denied  that  it  is  one  of  some  weight.  However,  if  due 
care  be  taken  to  operate  slowly,  and  to  allow  several  minutes  to 
elapse  between  each  tractive  eftbrt,  while  at  the  same  time  uterine 
contractions  be  stimulated  by  pressure  and  support,  this  need  not  be 
considered  a  contra-indication.  Besides  direct  traction  we  may  im- 
part to  the  instrument  a  gentle  waving  motion  from  handle  to  handle, 
which  brings  into  operation  its  power  as  a  lever  ;  but  this  must  not 
be  done  to  an}^  great  extent,  and  must  always  be  subservient  to  direct 
traction. 

Descent  of  the  Head. — Proceeding  thus  in  a  slow  and  cautious 
manner,  carefully  regulating  the  force  emploj^ed  according  to  the 
exigencies  of  the  case,  we  shall  perceive  that  the  head  begins  to 
descend  ;  and  its  progress  should  be  determined,  from  time  to  time, 
by  the  iingers  of  the  unemployed  hand. 

The  Rotation  from  the  Oblique  Diameter. — When  the  head  lies  in 
the  oblique  diameter,  as  it  descends,  in  consequence  of  its  perfect 
adaptation  to  the  pelvic  cavity,  it  will  turn  into  the  antero- posterior 
diameter  without  any  effort  on  the  part  of  the  operator,  provided 
only  that  the  traction  be  sufficiently  slow^  and  gradual.  As  the  head 
is  about  to  emerge,  it  is  necessary  to  raise  the  handles  towards  the 
mother's  abdomen.  More  than  usual  care  is  required  to  prevent 
laceration  of  the  perineum,  which  is  always  much  stretched  (Fig. 
158).  If,  as  often  happens,  the  pains  have  now  increased,  and  the 
perineum  be  very  thin  and  tense,  it  may  even  be  desirable  to  remove 


THE    FORCEPS. 


477 


the  blades  gently,  and  leave  the  case  to  be  terminated  by  the  natural 
powers:   but  if  due  precautions  arc  used  this  need  not  be  necessary. 


Fio.  158. 


Last  Stage  of  Extraction.     The  Handles  of  the  Forceps  are  'beiag  gradually  turned  upwards 
towards  the  Mother's  Abdomen. 

The  peculiarities  of  forceps  delivery  in  occipito-posterior  positions 
have  already  been  discussed  (p.  313),  and  need  not  be  repeated. 

High  Forceps  Operations. — •When  the  high  forceps  operation  has 
been  decided  on,  the  passage  of  the  blades  will  be  found  to  be  much 
more  difficult  from  the  height  of  the  presenting  part,  the  distance 
which  they  must  pass,  and,  in  some  cases,  from  the  mobility  of  the 
head  interfering  with  their  accurate  adaptation.  The  general  prin- 
ciples of  introduction  and  of  traction  are,  however,  identical.  If  the 
operation  be  attempted  before  the  head  has  entered  the  pelvic  brim, 
it  must  be  fixed,  as  much  as  possible,  by  abdominal  pressure.  In 
guiding  the  blades  to  the  head  special  care  must  be  taken  to  avoid 
any  injury  of  the  soft  parts,  especially  if  the  cervix  be  not  com- 
pletely out  of  reach.  For  this  purpose  it  may  even  be  advisable  to 
introduce  the  entire  left  hand  as  a  guide,  so  as  to  avoid  any  possi- 
bility of  injuring  the  cervix,  from  not  passing  the  instrument  under 
its  edge. 

Peculiar  Method  of  Introducing  the  Blades. — Some  authors  advise 
that,  in  such  cases,  the  blade  should  be  introduced  at  first  opposite 
the  sacrum,  until  the  point  approaches  its  promontory.  It  is  then 
made  to  sweep  round  the  pelvis,  under  the  protecting  fingers,  till  it 
reaches  its  proper  position  on  the  head.     This  plan  is  advocated  by 


478  OBSTETRIC  OPERATIONS. 

Eamsbotham,  Ilall  Davis,  and  other  eminent  practical  accouclieurs, 
and  it  is  certainly  of  service  in  some  cases  of  difficulty ;  especially 
Avhen,  from  any  reason,  it  is  not  possible  to  draw  the  nates  over  the 
edge  of  the  bed,  when  the  necessary  depression  of  the  handle  of  the 
upper  blade  is  difficult  to  effect.  It  involves,  however,  a  somewhat 
complicated  manoeuvre,  and  it  is  seldom  that  the  blades  cannot  be 
readily  introduced  in  the  usual  way. 

Necessity  of  Care  in  Locking. — In  locking  the  slightest  approach 
to  roughness  must  be  carefully  avoided,  for  the  extremities  of  the 
blades  are  now  within  the  cavity  of  the  uterus,  and  serious  injury 
might  easily  be  inflicted.  If  difficulty  be  met  with,  rather  than  em- 
ploy any  force,  one  of  the  blades  should  be  withdrawn,  and  reintro- 
duced in  a  more  favorable  direction.  If  the  blades 4iave  shanks  of 
sufficient  length,  there  should  be  no  risk  of  including  the  soft  parts 
of  the  mother  in  the  lock,  which,  in  a  badly  constructed  instrument, 
is  an  accident  not  unlikely  to  occur. 

Method  of  Traction.- — After  junction  traction  must  at  first  be  alto- 
gether in  the  axis  of  the  brim,  and  to  effect  this  the  handles  must  be 
pressed  Avell  backwards  towards  the  perineum.  As  the  head  descends 
it  will  probably  take  the  usual  turn  of  itself,  without  effort  on  the 
part  of  the  operator,  aud  the  direction  of  the  tractive  force  may  be 
gradually  altered  to  that  of  the  axis  of  the  outlet. 

If  the  pains  be  strong  and  regular,  and  there  be  no  indication  for 
immediate  delivery,  we  may  remove  the  forceps  after  the  head  has 
descended  upon  the  perineum,  and  leave  the  conclusion  of  the  case 
to  nature.  This  course  may  be  especially  advisable  if  the  perineum 
and  soft  parts  be  unusually  rigid  ;  but  generally  it  is  better  to  termi- 
nate labor  without  removing  the  instrument. 

Possible  Dangers  of  Forcejjs  Delivery.- — Before  concluding  this  sub- 
ject, reference  may  be  m^ade  to  the  possible  dangers  of  the  operation. 
I  would  here  again  insist  on  the  importance  of  distinguishing  be- 
tween the  high  and  low  forceps  operations,  which  have  been  so  unfor- 
tunately and  unfairly  confounded.  Eeasons  have  already  been  given 
for  rejecting  the  statistics  of  the  risks  attending  forceps  delivery  in 
the  latter  class  of  cases  (p.  3J3).  A  formidable  catalogue  of  dangers, 
both  to  the  mother  and  child,  might  easily  be  gathered  from  our 
standard  works  on  obstetrics.  Among  the  former  the  principal  are 
lacerations  of  the  uterus,  vagina,  and  perineum;  rupture  of  varicose 
veins,  giving  rise  to  thrombus  ;  pelvic  abscess,  from  contusion  of  the 
soft  parts ;  subsequent  inflammation  of  the  uterus  or  peritoneum  ; 
tearing  asunder  of  the  joints  and  symphyses;  and  even  fracture  of 
the  pelvic  bones.  A  careful  analysis  of  these,  such  as  has  been  so 
Avell  made  by  Drs.  Hicks  and  Philips,^  proves  beyond  doubt  that  the 
application  of  the  instrument  is  not  so  much  concerned  in  their  pro- 
duction, as  the  protraction  of  the  labor,  and  the  neglect  of  the  practi- 
tioner in  not  interfering  sufficiently  soon  to  prevent  the  occurrence 
of  the  evil  consequences  afterwards  attributed  to  the  operation  itself 
Many  of  these  will  be  found  to  arise  from  the  prolonged  pressure  on 

'  Obst.  Trans.,  vol.  xiii. 


THE    FORCEPS.  479 

the  soft  parts  within  the  pelvis,  and  the  subsequent  inflammation  or 
sloughing.  To  these  causes  may  be  referred  with  propriety  most 
cases  of  vesico  vaginal  fistula  (p.  484),  peritonitis,  and  metritis  fol- 
lowing instrumental  lal)or. 

Lacerations  and  similar  accidents  may,  however,  result  from  an 
incautious  use  of  the  instrument.  Slight  lacerations  of  theniucous 
membrane  of  the  vagina  are  probably  far  from  uncommon.  But  if 
these  cases  were  closely  examined,  it  would  be  found  that  the  fault 
lay  not  in  the  instrument,  but  in  the  hand  that  used  it.  Either  the 
blades  were  introduced  without  due  regard  to  the  axes  of  the  pelvis, 
or  they  were  pushed  forwards  with  force  and  violence,  or  an  instru- 
ment was  employed  unsuitable  to  the  case  (such  as  a  short  straight 
forceps  when  the  head  was  high  in  the  pelvis),  or  undue  haste  and 
force  in  delivery  were  used.  It  would  be  manifestly  unfair  to  lay 
the  blame  of  such  results  upon  the  forceps,  which,  in  the  hands  of  a 
more  judicious  and  experienced  practitioner,  would  have  effected  the 
desired  object  with  perfect  safety.  The  instrument  is  doubtless 
unsafe  in  the  hands  of  any  one  Avho  does  not  understand  its  use,  just 
as  the  scalpel  or  amputating  knife  would  be  in  the  hands  of  a  rash 
and  inexperienced  surgeon.  The  lesson  to  be  learnt  seems  to  be 
clearly,  not  that  the  dangers  should  deter  us  from  the  use  of  the 
forceps,  but  that  they  should  induce  us  to  study  more  carefully  the 
cases  in  which  it  is  applicable,  and  the  method  of  using  it  with 
safety. 

Possible  Rislcs  to  the  Child. — The  dangers  to  the  child  are  princi- 
pally, lacerations  of  the  integuments  of  the  scalp  and  forehead  ;  con- 
tusion of  the  face;  partial,  but  temporary,  paralysis  of  the  face  from 
pressure  of  a  blade  on  the  facial  nerve ;  depression  or  fracture  of  the 
cranial  bones;  injury  to  the  brain  from  undue  pressure  of  the  blades. 
These  evils  are  of  rare  occurrence,  and  when  they  do  happen,  gene- 
rally result  from  improper  management  of  the  operation — such  as 
undue  compression,  the  use  of  improper  instruments,  or  excessive 
and  ill-directed  eftbrts  at  traction — and  cannot,  therefore,  be  con- 
sidered as  in  any  way  contra-indicating  the  use  of  the  instrument. 
Many  of  the  more  common  results,  such  as  slight  abrasions  of  the 
scalp,  or  paralysis  of  the  face,  are  transitory  in  their  nature  and  of 
no  real  consequence. 

\_The  Forceps  in  America.— K\i\\o\x^\  obstetrical  forceps  were  first 
used  in  England,  other  countries  in  the  march  of  improvement  have 
made  great  changes,  not  onlj^  in  the  original  forms,  but  in  their  man- 
ner of  use :  and  different  shapes,  as  well  as  different  positions  of  the 
woman  in  application,  have  become  in  a  measure  almost  national. 
AVith  the  exception  of  having  adopted  almost  exclusively  the  French 
and  German  dorsal  decubitus  in  making  use  of  the  instruments,  Ave 
have  become  in  a  measure  eclectic  in  the  selection  of  the  latter  ;  medi- 
cal schools,  accoucheurs,  and  local  obstetrical  societies  influencing 
students  and  the  junior  members  of  the  profession,  to  adopt  the 
French,  German,  Englisli,  or  American  styles,  as  the  case  may  be, 
the  forceps  themselves  bearing  the  names  of  their  several  inventors, 


480  OBSTETRIC  OPERATIONS. 

or  compilers ;  for  some  are  a  true  compilation,  the  blade,  from  one 
contriver ;  fenestra!  opeuings,  another  ;  pelvic  curve,  a  third ;  width, 
a  fourth;  shanks,  a  lifth  ;  method  of  locking,  a  sixth;  etc.  etc.  For 
this  reason  the  late  Prof.  Hodge  named  his  forceps  the  eclectic^  al- 
though in  some  respects  entirely  original,  particularly  in  the  long 
superimposed  shanks,  a  great  improvement  for  operating  at  the  supe- 
rior strait,  and  avoiding  the  painful  stretching  of  the  posterior  com- 
missure. Dr.  Hodge  expended  a  great  deal  of  thought  and  money  in 
perfecting  his  forceps,  and  the  various  steps  in  the  process  were  marked 
by  a  new  form,  until,  from  a  heavy,  clumsy  instrument,  he  grad- 
ually evolved  what  was  at  one  time  regarded  as  a  wonderful  improve- 
ment upon  the  forceps  of  France  and  England. 

A  contemporary  of  Prof.  Hodge,  the  late  Prof  David  D.  Davis,  of 
London,  was  equally  anxious  to  perfect  the  instrument,  and  turned 
his  attention  especially  to  making  the  blades  light,  open,  and  to  so 
fit  the  sides  of  the  foetal  head  as  to  enable  traction  to  be  made  with- 
out much  pressure,  or  leaving  any  mark  on  the  child's  scalp.  There 
is  a  principal  of  mechanics  involved  in  his  instrument,  which  ho 
studied  to  perfect,  by  moulding  the  blades  so  as  to  obtain  consider- 
able coaptating  surface,  and  thus  by  increase  of  friction  avoid  undue 
and  dangerous  pressure.  The  Davis  blade  soon  began  to  effect 
changes  in  the  form  of  American  forceps,  and  by  the  addition  of 
long  handles,  and  some  alterations  of  shape,  weight,  and  curve,  be- 
came a  leading  feature  in  those  bearing  the  names  of  William  Harris, 
Prof.  Wallace,  of  the  Jefferson  Medical  College,  Dr.  Bethel,  and 
Albert  H.  Smith,  all  of  this  city.  The  short  Davis  instrument  was 
a  great  favorite  of  the  late  Prof.  Meigs,  and  Dr.  William  Harris,  both 
largely  engaged  in  obstetrical  practice,  as  well  as  teaching,  and  many 
a  delicate  woman,  with  wasting  forces,  was  aided  in  her  delivery  at 
their  hands,  and  surprised  to  find  no  mark  on  the  baby's  head,  and 
that  her  own  sufferings  could  be  so  gently  and  safely  relieved. 

Although  such  Avas  the  estimation  of  the  Davis  blade,  and  still  is 
in  many  parts  of  our  country,  it  does  not  appear  to  have  retained  its 
popularity  or  been  adopted,  as  its  mechanical  perfection  would  lead 
one  who  appreciates  it  to  suppose  it  would  have  been.  In  Great 
Britain,  the  favorite  forms  now  in  use  are  but  a  very  slight  improve- 
ment upon  the  forceps  of  a  hundred  years  ago,  except  in  finish  and 
material,  the  open  fenestrae  and  bevelled  blades  of  Davis  being  de- 
clined in  favor  of  the  looped  fenestrge  and  flat-edged  blades  in  use 
when  he  made  his  experiments  and  changes.  This  appears  to  have 
grown  out  of  a  practice  which  has  been  largely  adopted  in  Germany, 
Great  Britain,  and  many  parts  of  the  United  States,  in  applying  the 
forceps  to  the  foetal  head,  the  blades  being  introduced  at  the  sides  of 
■the  pelvis,  Avithout  much  reference  to  the  position  Avhich  the  head 
occupies.  As  compression  is  objected  to,  the  blades  are  made  long 
and  widely  separated  (3J  to  3|),  and  the  handles  short,  so  as  not  to 
allow  of  much  leverage.  As  the  blades  do  not  fit  the  head,  the 
mechanism  of  labor  as  taught  by  Hodge  has  been  much  simplified, 
as  it  is  not  necessary  to  learn  all  the  oblique  fittings  of  the  fenestra? 
over  the  parietal  protuberances  or  ears.     Dr.  Meigs  used  to  tell  the 


THE    FORCEPS. 


481 


students  that  the  forceps  was  tlie  ^^duh.Vs  insirurnent,^^  and  should  l:)c 
used  as  a  tractor ;  and  it  was  as  a  well-applied  mechanical  tractor 
that  he  advocated  the  use  of  the  Davis  blades  against  those  of  Sie- 
bold,  Levret,  Baudelocque,  and  Haighton,  employed  generally  in  our 
country  forty  years  ago.  Ilis  language  is  not  very  complimentary 
to  what  he  denominates  by  distinction  "^Ae  mother^s  instrument,''''  the 
form  being  better  adapted  for  saving  the  woman  than  the  foetus. 
("  Obstetrics,"  p.  540.) 

At  the  present  day  we  have  two  general  varieties  of  forceps  in 
use  in  the  United  States ;   under  each  of  which  may  be  placed  a  vast 
number  of  special  forms,  which  are  simply  changes 
upon  one  or  the  other  general  type,  according  to  the  Fig.  159. 

fancy  of  the  inventor.  At  the  head  of  one  type, 
may  be  placed  the  long  forceps  of  Prof.  Hodge,  de- 
signed to  be  adapted  to  the  sides  of  the  child's  head 
in  all  possible  cases:  and  of  the  other,  those  of  Prof. 
Simpson,  of  Edinburgh,  or  their  modification  by  Profs. 
Elliot  and  Bedford,  of  ISTevvr  York,  intended  to  be  used 
as  tractors,  and  applied  in  reference  to  the  sides  of 
the  mother's  pelvis,  rather  than  to  those  of  the  in- 
fant's head. 

Taking  the  long  forceps  of  Levret  and  Baudelocque 
as  improved  and  modified  by  ELodge  ;  with  the  blades 
of  Prof.  Davis  as  a  substitute,  and  handles  of  less 
curve  than  those  of  flodge ;  and  we  have  the  long 
forcops  of  Prof.  EUerslie  Wallace,  of  the  Jefferson 
College,  the  favorite  instrument  with  those  who  ])ur- 
chase  forceps  of  the  manufacturers  in  this  city.  Next 
in  popularity  are  the  instruments  of  Hodge,  Davis, 
and  Simpson,  Elliot,  Bedford,  and  a  few  others,  in  all 
about  a  dozen  forms  that  are  kept  in  stock.  The 
improvement  of  the  late  Prof.  Elliot  upon  the  instru- 
ment of  Simpson,  consists  in  narrowing  and  length- 
ening the  shanks;  widening  somewhat  the  fenestrte; 
elongating  the  blades  ;  gi  vi  ng  greater  security  against 
slipping  in  the  handles;  and  gauging  the  distance 
between  the  blades  by  a  milled-head  screw-stop  in 
the  end  of  the  handles  :  the  shanks  and  blades  are  an 
exact  counterpart  of  the  Miller  forcei)s  of  England, 
which  appeared  about  the  same  time,  1858. 

The  Hodge  forceijs  were  based  in  their  contrivance  Hodge  Forceps. 
upon  the  following  points:  1.  The  instrument  should 
be  shaped  to  the  contour  of  the  foetal  head,  and  have  sufficient  play 
to  allow  of  compression,  where  the  pelvis  is  too  narroAv  for  the  head 
to  pass  in  its  normal  condition.  2.  The  blades  should  be  so  arranged 
in  reference  to  the  shanks  and  handles  as  to  enable  them  to  seize  the 
head  of  the  foetus  in  its  bi-parietal  diameter  at  the  superior  straight, 
and  be  drawn  upon  in  the  direction  of  the  curve  of  the  pelvic  canal 
until  the  delivery  is  complete.  3.  The  long  forceps  ought  to  be 
competent  to  act  either  at  the  superior  strait  of  the  pelvis,  in  its 


482 


OBSTETRIC    OPERATIONS. 


cavity  or  at  its  outlet,  so  as  to  avoid  a  multiplicity  of  instruments 
and  their  attendant  expense.  And  4.  The  instrument  should  not 
cut  the  scalp  of  the  child  if  properly  adjusted,  or  injure  the  soft 
parts  of  the  mother. 

It  would  be  folly  to  claim  that  all  this  could  or  has  been  accom- 
])lislied;  as  there  must  necessarily  be  exceptional  cases  in  all  the  points 
given  ;  hence  the  contrivance  of  the  forceps  of  Tarnier  and  Cleemann 
for  certain  presentations  above  the  superior  strait ;  and  the  long  and 
short  convertible  instruments  of  a  few  inventors.  There  are  many 
cases  of  labor  in  the  higher  walks  of  life   where,  although  there  is 

no  obstruction,  still  the  women  re- 
FiG.  160.  Fig.  101.  quire  manual  or  instrumental  as- 

sistance, as  they  cannot  deliver 
themselves  for  want  of  sufficient 
contractile  muscular  force.  Such 
Avomen  require  that  the  forceps 
used  should  be  easily  introduced ; 
should  act  simply  as  tractors ; 
control  the  movement  of  the  foetal 
head  by  being  well  fitted  to  its 
shape,  and  leave  no  effect  upon 
the  scalp  or  vulva.  Although 
these  requisites  may  be  filled  by 
the  Hodge  instrument,  it  is  this 
class  of  cases  that  has  demanded  a 
lighter  and  more  roomy  pair  of 
forceps,  such  as  that  devised  by 
Davis. 

As  the  teaching  of  the  Jefferson 
Medical  College  under  Dr.  Meigs, 
favored  as  we  have  stated  the  for- 
ceps of  Davis,  so  his  successor  in 
carrjang  out  in  a  measure  the 
same  views,  has  combined  the 
blades  of  the  Davis  pattern,  with 
the  long  handles  of  Hodge,  in  con- 
triving the  IVnllace  forceps,  now 
so  much  in  use  by  the  large  number 
of  graduates  of  this  school.  As 
Davis  Forceps.  compared  with  the  Hodge  instru- 
ment, it  is  one  inch  shorter  (15 
inches  against  16) ;  the  blades  are  of  the  same  length  (6  inches)  the 
fenestras  are  more  open;  the  shanks  are  only  half  the  length,  giving 
a  much  greater  compressing  power  ;  and  the  handles  are  of  the  same 
measurementfrom  pivot  to  hooks.  Both  have  the  Siebold  lock,  over 
which  we  believe  the  broad-topped  button  and  notch  to  possess  some 
advantages;  and  the  Wallace  is  somewhat  heavier  than  the  Hodge 
which  should  Aveigh  17  ounces. 

The  short  Davis  instrument  made  for  Prof  Meigs  under  direction 
of  the  inventor   weighed  10|  ounces,  and   measured   12   inches   in 


WaUace  Forceps. 


THE    FORCEPS, 


483 


Fig.  162. 


length  ;  fcnestraj  5  inches  long,  2  inches  "vvide ;  Llades  separated  2| 
inches.  Handles  4^  inches  to  lock,  which  was  of  the  Sinellie  or 
English  |)attern.  A  recently  purchased  y^air  in  possession  of  the 
editor  is  13|-  inches  long,  with  5  inch  handles,  a  button  lock,  2  inch 
close  set  shanks,  and  6i  inch  blades.  I  believe  tlie  changes  are 
decided  improvements,  especially  the  lock  and  elongated  handles. 
It  has  answered  admirably  in  adynamic  cases,  requiring  only  a  few 
pounds  of  tractile  assistance.  The  Davis  blades  have  been  added  to 
long  handles,  and  the  whole  made  of  steel  and  marvellously  light,  at 
the  special  request  of  a  few  accoucheurs,  who  wished  thcni  to  aid  in 
some  cases  of  arrest  at  the  perineum. 

The  late  Prof.  George  T.  Elliot,  of  New  York,  who  received  much 
of  his  practical  obstetrical  training  in  the  Dublin  Lying-in  Hospital, 
imbibed  the  teachings  of  the  English  school,  and  be- 
came impressed  with  the  valueof  the  system  as  taught 
by  Simpson;  after  the  principle  of  whose  forceps, 
modelled  somewhat  after  that  of  the  late  Prof.  Gun- 
ning G.  Bedford,  of  New  York,  he  in  1858,  presented 
to  the  medical  profession  the  instrument  that  bears 
his  name.  The  forceps  of  Prof.  Bedford  has  a  trac- 
tion ring  on  each  side,  where  the  Elliot  has  a  cornu, 
has  a  button  joint,  instead  of  a  Sniellic,  has  no 
screw  stop,  and  has  diverging  instead  of  superim- 
posed shanks.  These  points  have  generally  been 
considered  as  improvements,  and  hence  the  Elliot 
has  taken  precedence  in  large  measure  over  the 
Bedford  instrument  in  New  York  sales,  the  two 
being  the  leading  forceps  in  demand.  The  instru- 
ment of  White,  of  Buffalo,  is  perhaps  next,  and 
then  Hodge's.  But  few  of  Prof.  Wallace's  forceps, 
the  leading  instrument  in  the  Philadelphia  trade,  are 
ordered.  The  White  is  a  long  forceps,  a  compound 
of  the  Elliot  blade,  long  superimposed  shanks  of 
Hodge,  Siebold  lock,  and  short  corrugated  steel 
handles  bowed  out  like  dental  forceps,  and  ending 
in  thin  blunt  hooks. 

The  Sawyer  and  Simpson  short  forceps  are  about 
equally  in  demand  in  Now  York.  The  former  is 
unknown  to  the  trade  here  ;  and  but  comparatively 
few  of  the  Simpson  are  sold,  although  the  system  of 
their  application  has  several  advocates  in  Phila- 
delphia. 

We  have  here  a  representation  of  one  of  the 
lightest  of  all  the  varieties  of  the  short  forceps,  weighing  but  5 
ounces,  and  measuring  9|-  inches  in  length ;  the  handle  being  3  inches, 
shank  1|,  and  chord  of  blade-curve  5^.  The  blades  are  IJ  inches 
wide,  with  oval  fenestrte  |  inch  wide,  and  separated  2f  inches  at  their 
widest  part,  and  f  inch  at  the  tips. 

This  instrument  was  invented  about  three  years  and  a  half  ago,  by 
Prof.  Edw.  Warren  Sawyer,  of  Eush  Medical  College,  Chicago,  and 


Elliot  Forceps. 


484 


OBSTETRIC    OPERATIONS 


Fig.  163. 


has  been  liiglily  commended  bj  Prof.  Bjford  and  otlicrs.  The  for- 
ceps has  the  blades  of  Davis,  superimposed  shanks  of  Hodge,  and 
lock  of  Smellie,  with  hard-rubber  plates  moulded  hot  upon  the  handles. 
The  several  parts  have  been  somewhat  modified  ;  the  object  being  to 
secure  a  tractor  for  cases  of  deficient  expulsive  force,  where  the  foetal 
head  is  low  in  the  pelvis. 

Professor  Sawyer  says:  "In  the  labors  to  which  my  forceps  is 
applicable  it  is  not  necessary  for  the  operator's 
body  to  be  in  line  with  the  pelvic  axis.  My 
mode  of  procedure  is  the  following :  the 
woman  is  placed  upon  her  back  and  drawn  to 
the  edge  of  the  bed,  the  outside  leg  is  now 
flexed  ;  beneath  this  flexed  extremity  and  the 
bed  covering,  I  apply  the  forceps — often  using 
but  one  hand  in  the  operation.  When  the 
instrument  is  locked,  I  grasp  the  handle  in 
such  a  manner  that  the  palm  of  the  hand  looks 
upward;  one  hook  then  rests  naturally  upon 
the  extensor  surface  of  the  first  phalanx  of 
the  index  finger,  while  the  other  hook  rests 
upon  a  corresponding  part  of  the  thumb.  . 
When  thus  adjusted,  I  lift  the  head  from  the 
pelvic  outlet,  at  the  same  time  invoking  the 
pendulum  movement  if  desired.  At  this 
moment  the  advantage  of  the  hooked  handle 
is  very  apparent  to  the  operator." 
"  All  practitioners  must  have  often  felt,  daring 
the  last  moments  of  labor,  when  the'  uterus 
and  the  mother  seemed  fatigued,  the  need  of 
a  little  lielp  to  the  expansive  powers.  .  The 
ordinary  instruments  are  too  formidable  to  be 
used  at  the  last  moment,  and  it  is  then  that 
this  little  forceps  is  useful." 
I  have  given  the  names  and  characters  of  the  various  forceps 
most  in  use  in  New  York  and  Philadelphia;  and  by  the  large  num- 
ber of  graduates'  of  their  respective  schools  as  shown  by  their  pre- 
ferences in  making  purchases  of  the  leading  instrument  makers  of 
the  two  cities.  The  mechanism  of  instrumental  delivery  is  much, 
simplified  by  applying  the  forceps  to  whatever  parts  of  the  foetal 
head  may  be  opposite  the  sides  of  the  pelvis;  but  it  is  very  ques- 
tionable whether  it  is  the  scientific  method,  or  the  safer  for  the  child. 
With  one  blade  over  the  side  of  the  occiput,  and  the  other  over  that 
of  the  forehead,  which  is  tlie  manner  of  seizure  in  oblique  positions 
of  the  vertex,  we  certainly  have  not  a  very  secure  hold,  and  run 
some  risk  of  injury  to  the  foetus.  The  advocates  of  this  system 
claim  that  they  use  no  compression,  only  a  simple  traction;  which 
may  be  true  in  one  sense,  but  amounts  to  the  same  in  effect,  else  how 
could  Dr.  Elliot,  by  traction  with  great  force,  straighten  out  one  of 
the  blades  of  his  Simpson  forceps,  as  related  in  the  "  IST.  Y.  Journ.  of 
Med."  for  September,  1858,  page  1(31,  in  the  paper  which  he  pre- 


Sawyer  Forceps. 


THE    FORCEPS. 


485 


sented,  describing  his  new  forceps  and  a  number  of  cases  in  which 
he  had  tested  them.  It  makes  but  little  dilference  whether  we  com- 
press the  liead  before  we  begin  to  pull,  or  pull  so  as  to  wedge  the 
head  between  the  blades  and  thus  compress  it,  except  as  to  the  dift'er- 
ence  of  fit  in  the  two  instances;  the  adjusted  and  even  pressure, 
being  the  less  likely  to  injure  the  foetus.  I  have  always  believed 
that  the  forceps  should  fit  the  head,  and  that  the  student  should  be 
taught  how  to  accomplish  it  correctly  in  the  various  positions  of  the 
foetus.  If  the  student  has  a  mechanical  turn  of  mind,  a  delicate 
sense  of  touch,  and  a  clear  head,  he  will  soon  learn  ;  if  he  is  not  a 
mechanic,  he  will  be  forced  to  adopt  a  more  simple  method  of  de- 
livery. In  a  large  city,  there  are  but  few  first  class  obstetrical 
manipulators  as  a  general  rule,  and  they  are  usually  well  known  as 

Fia.  164. 


Application  of  the  Forceps  at  the  Inferior  Strait. 


such,  for  the  reason  that  but  few  have  all  the  requisites  to  enable 
them  to  achieve  notoriety;  and  yet  there  are  hundreds  who  can  de- 
liver a  woman  with  forceps  moderately  well.  To  one,  the  mechan- 
ism of  Hodge  is  a  simple  matter,  and  soon  mastered  ;  to  another,  it  is 


486  OBSTETRIC  OPERATIONS. 

a  useless  complication,  and  he  prefers  the  more  simple  system. 
Hence  the  great  differences  between  obstetricians,  as  to  the  best  in- 
strument, and  the  best  method  of  application.  Some  of  the  vast 
array  of  patterns  have  decided  merit,  and  display  much  mechanical 
skill ;  while  others  serve  only  to  amuse  the  educated  examiner.  One 
obstetrician,  like  Elliot,  uses  a  variety  of  forceps  one  after  another  in 
the  same  case,  and  pulls  with  great  force  ;  while  another  confines  his 
work  almost  to  one  instrument,  adjusts  it  easily,  pulls  moderately, 
and  seldom  fails.  There  are  no  doubt  exceptions,  but  certainly  the 
most  delicate  manipulators  we  have  seen,  believed  in  and  practised 
the  teachings  of  Hodge  and  Meigs.  There  may  be  cases  where  it 
might  be  well  to  practise  the  method  of  Simpson,  as  is  done  occa- 
sionally by  some  of  our  leading  practitioners ;  but  we  cannot  see 
why  his  plan  of  delivery  should  be  exclusively  used  on  any  mode  of 
scientific  reasoning. 

I  present  a  series  of  plates  in  illustration  of  the  American 
method  of  delivery  with  the  forceps ;  the  position,  as  will  be  seen, 
being  that  of  France  and  Germany' — on  the  back.  When  it  is  de- 
cided to  use  the  forceps,  in  almost  all  cases  in  the  United  States,  the 
patient  is  brought  to  the  edge  of  the  bed  on  her  back,  with  her  nates 
close  to  the  edge,  her  feet  on  two  chairs,  and  her  knees  widely  sepa- 
rated, as  in  the  plate  above.  The  patient  is  covered  with  a  sheet,  or 
heavier  covering  if  in  winter,  and  there  is  no  necessity  of  exposure, 
as  the  whole  manipulation  may  be  done  by  the  sense  of  touch.  The 
position  is  by  far  the  most  convenient  for  the  obstetrician,  and  enables 
him  much  more  easily  to  keep  in  his  mind  all  the  anatomical  rela- 
tions of  the  foetus  and  pelvis,  than  when  in  the  Enghsh  decubitus. 
We  study  the  anatomy,  with  the  subject  on  the  back,  and  the 
mechanism  of  labor  in  front  of  the  pelvis,  or  manikin,  then  why 
complicate  matters  by  a  change  of  position,  which  to  say  the  least, 
is  a  very  awkward  one,  particularly  in  introducing  the  long  forceps, 
setting  them  according  to  the  instructions  of  Hodge,  and  carrying 
them  forward  between  the  thighs  as  the  head  emerges  ?  I  have 
used  the  short  forceps  in  an  exhausted  case,  with  the  woman  on  her 
side,  but  found  it  much  less  convenient  for  the  various  movements, 
although  I  soon  delivered  the  foetus.  As  to  the  question  of  exposure, 
there  is  less  in  appearance  than  in  fact,  in  the  English  position,  in 
many  cases.  If  the  patient  and  nurse  are  fastidious  and  careful 
during  the  use  of  the  forceps,  the  accoucheur  can  manage  without 
his  eyes  in  a  large  proportion  of  cases ;  but  the  fault  of  exposure 
lies  more  frequently  in  the  temporary  reckless  indifference  begotten 
of  pain  and  suffering  in  the  woman,  than  in  any  act  of  the  accou- 
cheur, if  inclined  to  spare  the  feelings  of  his  patient  as  much  as 
possible. 

The  long  forceps,  with  its  pelvic  curve,  was  specially  designed  for 
use  at  the  superior  strait  of  the  pelvis,  the  curve  of  the  blades,  as  in 
the  Davis  instrument  modified  by  Wallace,  being  intended  to  cor- 
respond with  the  direction  of  the  occipito-mental  diameter  of  the 
fcetal  head.  The  long  superimposed  shanks  of  several  varieties  of 
the  long  forceps  will  here  be  found  valuable,  as  the  lock  is  not  intro- 


THE    FORCEPS. 


487 


duced,  or  the  posterior  commissure  of  the  vulva  widely  stretched. 
If  the  head  is  entirely  above  the  strait,  the  line  of  the  blades  must 
be  changed  correspondingly,  in  order  to  apply  them  properly,  and 
keep  the  line  of  traction  within  the  coccyx ;  and  even  then,  to  draw 


Fig.  165. 


Application  of  tlie  Forceps  with  the  Head  at  the  Superior  Strait ;  Ihe  left  blade  held  in  place  by  an 

Assistant. 

in  the  proper  direction,  the  left  hand  must  act  at  first  in  a  backward 
direction  from  the  lock  ;  while  the  right  brings  the  handles  down- 
ward, forward,  and  then  upward  ;  both  hands  describing  a  curve,  but 
that  of  the  right  being  much  the  greater.  The  peculiar  forceps  of 
Tarnier,  or  of  Cleeraann,  being  designed  to  meet  this  form  of  exi- 
gency, may  be  brought  into  requisition. 

In  latter  years  it  has  become  much  more  common  than  formerly 
to  introduce  the  forceps  into  the  uterus,  before  it  is  full^y  dilated,  in 
consequence  of  the  success  claimed  for  the  plan  as  carried  out  in  the 


488 


OBSTETRIC    OPERATIONS, 


Dublin  Lying-in  Hospital.  As  this  should  never  be  done  where  the 
OS  is  not  readily  dilatable,  and  requires  much  skill  in  execution,  it  is 
not  safe  to  recommend  its  general  adoption  in  cases  of  delay  in  pri- 
vate practice. 

The  forceps  should  not  be  introduced  with  any  force,  but  the  left 
blade  should  be  slid  in  gently,  and  with  a  spiral  motion,  and  then 
the  right ;  care  being  taken  that  they  should  also  lock  without  force, 
which  they  will  do  if  properly  adjusted.  Traction  is  to  be  exerted 
slowly,  and  during  a  pain,  the  whole  movement  being  made  to  cor- 
respond with  the  natural  as  closely  as  possible. 

Fig.  166. 


Direction  of  the  Forceps  as  the  Head  is  being  Delivered. 

As  the  foetal  head  comes  under  the  arch  of  the  pubes,  the  handles 
of  the  forceps  must  rise  more  and  more  from  the  bed,  until  at  last 
they  are  over  the  abdomen,  as  the  head  emerges  from  the  perineum. 
This  last  movement  of  instrumental  delivery  should  be  a  very  slow 
one,  for  fear  of  rupture.  It  has  been  proposed  to  remove  the  blades 
before  delivery  is  complete ;  but  there  is  no  occasion  for  this,  if  the 
forceps  is  applied  to  the  sides  of  the  head  over  the  parietal  protru- 
berances ;  as  where  these  protrude,  and  the  blades  are  flat  and  thin, 
there  is  verv  little  additional  space  required.  With  such  instruments 
as  the  old  Levret,  Baudelooque,  and  Rohrer  forceps,  with  looped  or 
kite-shaped  fenestrge,  and  thick  edges,  this  was  a  much  more  impera- 


THE    VECTIS — THE    FILLET. 


489 


tive  direction,  than  with  the  better  instruments  of  the  present  day. 
With  a  Sawyer  forceps  the  perineum  ought  to  he  safer,  and  under 
better  control  than  without.  When  the  perineum  is  thought  to  be 
in  danger,  the  process  of  distension  should  be  retarded  through  two 
or  three  pains,  or  even  more  if  required,  instead  of  drawing  the  head 
through  at  once. 

After  the  head  is  delivered,  if  the  cord  is  not  around  the  neck, 
and,  therefore,  in  danger  from  pressure,  the  body  should  be  allowed 
to  remain  until  the  uterus  has  well  contracted  upon  it,  for  fear  of 
hemorrhage  after  delivery  from  uterine  inertia. — Ed.] 


CHAPTER  IV 


THE  VECTIS — THE  FILLET. 


Fig.  167. 


In"  connection  with  the  subject  of  instrumental  delivery  it  is  essen- 
tial to  say  something  of  the  use  of  the  vectis,  on  account  of  the  value 
wdiich  was  formerly  ascribed  to  it,  which  was  at  one  time  so  great  in 
this  country  that  it  became  the  favorite  instrument  in  the  metropolis  ; 
Denman  saying  of  it  that  even  those  who  employed 
the  forceps  wore  "  very  willing  to  admit  the  equal,  if 
not  superior,  utility  and  convenience  of  the  vectis." 
Even  at  the  present  day,  there  are  practitioners  of 
no  small  experience  who  believe  it  to  be  of  occa- 
sional great  utility,  and  use  it  in  preference  to  the 
forceps  in  cases  in  which  slight  assistance  only  is 
required.  In  spite,  however,  of  occasional  attempts 
to  recommend  its  use,  the  instrument  has  fallen  into 
disfavor,  and  may  be  said  to  be  practically  obsolete. 

Natwe  of  the  Instrument. — The  vectis,  in  its  most 
approved  form,  consists  of  a  single  blade,  not  unlike 
that  of  a  short  straight  forceps,  attached  to  a  wooden 
handle.  A  variety  of  modilications  exist  in  its  shape 
and  size.  The  handle  has  been  occasionally  manu- 
factured, for  the  convenience  of  carriage,  with  a  hinge 
close  to  the  commencement  of  the  blade  (Fig.  167),  or 
with  a  screw  at  the  point  where  the  handle  and  blade 
join.  The  power  of  the  instrument,  and  the  facility 
of  introduction,  depend  very  much  on  the  amount  of 
curvature  of  the  blade.  If  this  be  decided,  a  firmer  hold  of  the  head 
is  taken  and  greater  tractive  force  is  obtained,  but  the  dif&culty  of 
introduction  is  increased. 

The  vectis  is  used  either  as  a  lever  or  a  tractor.     When  employed  in 
the  former  way,  the  fulcrum  is  intended  to  be  the  hand  of  the  ope- 
32 


Vectis  'witli 
Hinsred  Haadle. 


490 


OBSTETRIC    OPERATIONS, 


rator ;  but  the  risk  of  using  the  maternal  structures  asii2^oint  d'appui^ 
and  the  inevitable  danger  of  contusion  and  laceration  which  must 
follow,  constitute  one  of  the  chief  objections  to  the  operation.  Its 
value  as  a  tractor  must  always  be  limited  and  quite  inferior  to  that 
of  the  forceps,  while  it  is  as  difficult  to  introduce  and  manipulate. 

Gases  in  ivhick  it  is  Ap'plicahle. — The  vectis  has  been  recommended 
in  cases  in  which  the  low  forceps  operation  is  suitable,  provided  the 
pains  have  not  entirely  ceased.  There  is  no  doubt  that  it  may  be 
quite  capable  of  overcoming  a  slight  impediment  to  the  passage  of 
the  head.  It  is  applied  over  various  parts  of  the  head,  most  com- 
monly over  the  occiput,  in  the  same  manner,  and  with  the  same 
precautions,  as  one  blade  of  the  forceps.  Dr.  Rarasbotham  says  "we 
shall  find  it  necessary  to  apply  it  to  different  parts  of  the  cranium, 
and  perhaps  the  face  also,  successively,  in  order  to  relieve  the  head 
from  its  fixed  condition,  and  favor  its  descent."  Such  an  operation 
obviously  requires  quite  as  much  dexterity  as  the  application  of  the 
forceps;  while,  if  we  bear  in  mind  its  comparatively  slight  power,  and 
the  risk  of  injury  to  the  maternal  structures,  we  must  admit  that  the 
disuse  of  the  instrument  in  modern  practice  is  amply  justified. 

The  vectis  may,  however,  find  a  useful  application  when  employed 
to  rectify  malpositions,  especially  in  certain  occipito-posterior  present- 
ations. This  action  of  the  instrument  has  already  been  considered 
(p.  314),  and,  under  such  circumstances,  it  may  prove  of  service 
where  the  forceps  is  inapplicable.  When  so  employed  it  is  passed 
carefully  over  tlie  occiput,  and,  while  the  maternal  structures  are 
guarded  from  injury,  downward  traction  is  made  during  the  con- 
tinuance of  a  pain.  So  used,  its  applica- 
tion is  perfectly  simple  and  free  from  dan- 
ger, and  for  this  purpose  may  be  retained 
as  a  part  of  the  obstetric  armamentarium. 
The  fillet  is  the  oldest  of  obstetric  in- 
struments, having  been  frequently  em- 
\  ployed  before  the  invention  of  the  forceps, 
n  and  even  in  the  time  of  Smellie  it  was 
ll  much  used  in  the  metropolis.  It  has  since 
i;!  completely  fallen  out  of  favor  as  a  scientific 
llj  instrument,  although  its  use  is  every  now 
f!  and  again  advocated,  and  it  is  certainlj^  a 
;;■  favorite  instrument  with  some  practition- 
l\  ers.  This  is  to  be  explained  by  the  appa- 
li  rent  simplicity  of  the  operation,  and  the 
j  fact  that  it  can  generally  be  performed 
ij  without  the  knowledge  of  the  patient ;  the 
\  latter,  however,  is  one  strong  reason  why  it 
i";      should  not  be  used. 

\\  Nature  of  the  Instrument. — The  fillet  con- 

:fP     sists,  in  its  most  improved  form  (that  which 

i''      is  recommended  by    Dr.  Eardley  Wilmot^ 

wiimot's  Fiuet.  (^j^g-  1^8),    of  a  slip  of  whalebouc  fixed 


Fig.  168. 


■  Obst.  Trans.,  vol.  xv. 


OPERATIONS    INVOLVING    DESTRUCTION    OF    FCETUS.  491 

into  a  handle,  composed  of  two  separate  halves,  which  join  into  one. 
The  whalebone  loop  is  slipped  over  either  the  occiput  or  face,  and 
traction  used  at  the  handle. 

Ohjections  to  its  Use. — When  applied  over  the  face,  after  the  head 
has  rotated,  it  would  probably  do  no  harm,  but  if  it  were  so  placed 
wlien  the  head  was  high  in  the  pelvis,  traction  would  necessarily 
produce  extension  of  the  chin  before  the  proper  time,  and  would 
thus  interfere  with  the  natural  mechanism  of  delivery.  If  placed 
over  the  occiput,  it  is  impossible  to  make  traction  in  the  direction 
of  the  pelvic  axes,  as  the  instrument  will  then  infallibly  slip.  If 
traction  be  made  in  any  other  direction,  there  must  be  a  risk  of  in- 
juring the  maternal  structures,  or  of  changing  the  position  of  the 
head.  Hence  there  is  every  reason  for  discarding  the  fillet  as  a  trac- 
tor, or  as  a  substitute  for  the  forceps,  even  in  the  simplest  cases. 

It  is  quite  possible  that  it  may  find  a  useful  application  in  certain 
cases  in  which  the  vectis  may  also  be  used,  viz.,  as  a  rectifier  of  mal- 
position, and,  from  the  comparative  facility  of  its  introduction,  it 
would  probably  be  the  preferable  instrument  of  the  two. 


CHAPTEE  y. 

OPEEATIONS  INVOLVING  DESTEUCTION"  OF  THE  FCETUS, 

Operations  involving  the  destruction  and  mutilation  of  the  child 
were  among  the  first  practised  in  midwifery.  Craniotomy  was  evi- 
dently known  in  the  time  of  Hippocrates,  as  he  mentions  a  mode  of 
extracting  the  head  by  means  of  hooks.  Celsus  describes  a  similar 
operation,  and  was  acquainted  with  the  manner  of  extracting  the 
foetus  in  transverse  presentations  by  decapitation  ;  similar  procedures 
were  also  practised  and  described  by  Aetius  and  others  among  the 
ancient  Avriters.  The  physicians  of  the  Arabian  school  not  only 
employed  perforators  for  opening  the  head,  but  were  acquainted  with 
instruments  for  compressing  and  extracting  it. 

Religious  Ohjections  to  Craniotorn.y . — Until  the  end  of  the  seven- 
teenth century  this  class  of  operation  was  not  considered  justifiable 
in  the  case  of  living  children  ;  it  then  came  to  be  discussed  Avhether 
the  life  of  the  child  might  not  be  sacrificed  to  save  that  of  the  mother. 
It  was  authoritatively  ruled  by  the  Theological  Faculty  of  Paris, 
that  the  destruction  of  the  child  in  any  case  was  mortal  sin.  "Si 
I'on  ne  pent  tirer  I'enfant  sans  le  tuer,  on  ne  pent  sans  pechd  mortel 
le  tirer."  This  dictum  of  the  Eoman  Church  had  great  influence  on 
Continental  midwifery,  more  especially  in  France,  where,  up  to  a 
recent  date,  the  leading  obstetricians  considered  craniotomy  to  be 
only  justifiable  when  the  death  of  the  foetus  had    been  positively 


402  OBSTETRIC  OPERATIONS. 

ascertained.  Even  at  the  present  day  there  are  not  wanting  practi- 
tioners wlio,  in  their  praiseworthy  objection  to  the  destruction  of  a 
living  child,  counsel  delay  until  the  child  has  died  ;  a  practice  thor- 
oughly illogical,  and  only  sparing  the  operator's  feelings  at  the  cost 
of  greatly  increased  risk  to  the  mother.  In  England,  the  safety  of 
the  child  has  always  been  considered  subservient  to  that  of  the 
mother  ;  and  it  has  been  admitted  that,  in  every  case  in  which  the 
extraction  of  a  living  foetus  by  any  of  the  ordinary  means  is  impos- 
sible, its  mutilation  is  perfectly  justifiable. 

Unjustifiable  Frequency . — It  must  be  admitted  that  the  frequency 
with  whicli  craniotomy  has  been  performed  in  this  country  constitutes 
a  great  blot  on  British  Midv/ifery.  During  the  mastej'ship  of  Dr. 
Labbat,  at  the  Eotunda  Hospital,  the  forceps  was  never  once  applied 
in  21,867  labors.  Even  in  the  time  of  Clarke  and  Collins,  when  its 
frequency  was  much  diminished,  craniotomy  was  performed  three  or 
four  times  as  often  as  forceps  delivery.  These  figures  indicate  a 
destruction  of  foetal  life  which  we  cannot  look  back  to  without  a 
shudder,  and  which,  it  is  to  be  feared,  justify  the  reproaches  which 
our  Continental  brethren  have  cast  upon  our  practice.  Fortunately, 
professional  opinion  has  now  completely  recognized  the  sacred  duty 
of  saving  the  infant's  life,  whenever  it  is  practicable  to  do  so ;  and 
British  obstetricians  now  teach,  as  carefully  as  those  of  any  other 
nation,  the  imperative  necessity  of  using  every  endeavor  to  avoid 
the  destruction  of  the  foetus. 

Division  of  the  Suhjeci. — The  operation  now  under  consideration 
may  be  necessary  :  1st,  when  the  head  requires  either  to  be  simply 
perforated,  or  afterwards  more  completely  broken  up  and  extracted ; 
an  operation  which  has  received  various  names,  but  is  generally 
known  in  this  country  as  craniotomy,  and  which  may  or  may  not 
require  to  be  followed  by  further  diminution  of  the  trunk.  2dly, 
when  the  arm  presents,  and  turning  is  impossible  ;  this  necessitates 
one  of  two  procedures,  decajntation  with  the  separate  extraction  of 
the  body  and  head,  or  evisceration.  In  both  classes  of  cases  similar 
instruments  are  employed,  and  those  generally  in  use  at  the  present 
time  may  be  first  briefly  described. 

Description  of  Instruinents  Em^ployed. — 1.  The  object  of  l\\e  perfo- 
rcUor  is  to  pierce  the  skull  of  the  child,  so  as  to  admit  of  the  brain 
being  broken  up,  and  the  consequent  collapse  and  diminution  in  size 
of  the  cranium.  The  perforator  invented  by  Denman,  or  some  modi- 
fication of  it,  has  been  principally  employed.  It  requires  the  handles 
to  be  separated  in  order  to  open  the  blades,  and  this  cannot  be  done 
by  the  operator  himself.  This  dif&culty  is  overcome  in  the  modifi- 
cation of  Naegele's  perforator  used  in  Edinburgh,  in  which  the 
handles  are  so  constructed  that  they  open  the  points  when  pressed 
together,  and  are  separated  by  a  steel  rod,  with  a  joint  at  its  centre, 
to  prevent  their  opening  too  soon.  By  this  arrangement  the  instru- 
ment can  be  manipulated  by  one  hand  oxAj.  The  sharp-pointed 
]iortion  has  an  external  cutting  edge,  with  projecting  shoulders  at 
its  base,  to  prevent  its  penetrating  too  far  into  the  cranium.  Many 
modifications  of  these  arrangements  have  since  been  contrived  (Figs. 


OPERATIONS    INVOLVING    DESTRUCTION    OF    F(ETUS. 


493 


169,  170,  171).     In  some  parts  of  the  Continent  a  perforator  is  used 
constructed  on  the  principle  of  tlie  trephine  ;  but  this  is  vastly  more 


Fig.  169. 


Fig.  170. 


Fig.  171. 


Various  forms  of  Perforators. 

difficult  to  work,  and  has  the  great  disadvantage  of       Figs.  172,  173. 
simply  boring  a  hole  in  the  skull,  instead  of  split- 
ting it  up  as  is  done  by  the  sharp-pointed  instru- 
ment. 

The  instruments  for  extraction  are  the  crotchet 
and  craniotomy  forceps. 

Crotchets  and  Craniotomy  Forceps. — The  crotchet 
is  a  sharp-pointed  hook  of  highly-tempered  steel, 
which  can  be  fixed  on  some  portion  of  the  skull, 
either  internal  or  external,  traction  being  made 
by  the  handle.  The  shank  of  the  instrument 
is  either  straight  or  curved  (Figs.  172  and  173), 
the  latter  being  preferable,  and  it  is  either  at- 
tached to  a  wooden  handle  or  forged  in  a  single 
piece  of  metal.  A  modification  of  this  instrument 
is  known  as  Oldharn's  vertehral  hook.  It  consists  of 
a  slender  hook,  measuring,  with  its  handle,  13  inches 
in  length,  which  is  passed  through  the  foramen 
magnum,  and  fixed  in  the  vertebral  canal,  so  as  to 
secure  a  firm  hold  for  traction.^  All  forms  of 
crotchets  are  open  to  the  serious  objection  of  being 
liable  to  slip,  or  break  through  the  bone  to  which 
they  are  fixed,  so  wounding  either  the  soft  parts  of 
the  mother,  or  the  fingers  of  the  operator  placed  as  crotchets. 

'  [The  American  c/tiarded  crotchet  is  constructed  like  a  pair  of  forceps,  the  end  of  one 
blade  guarding  the  hook  on  the  otlier,  so  tliat  if  tliehold  of  the  latter  should  give  way 
and  slip,  it  cannot  injure  the  soft  parts  or  hand  of  the  operator  as  it  immediately  shuts 
against  the  guard. — Ed.] 


%J 


494 


OBSTETRIC    OPERATIONS. 


a  guard.    Hence  they  are  discountenanced  by  most  recent  writers,  and 
may  with  propriety  be  regarded  as  obsolete  instruments. 

(Jraniotomy  Force'ps  are  preferahle  for  Extraction.  — Their  place  as 
tractors  is  well  supplied  by  the  more  modern  craniotomy  forceps 
(Fig.  174).  These  are  intended  to  lay  hold  of  the  skull,  one  blade  being- 
introduced  within  the  cranium,  tlie  other  externally,  and,  when  a  firm 
grasp  has  been  obtained,  downward  traction  is  made.  A  second  object 
it  fulfils  is,  to  break  awa}'  and  remove  portions  of  the  skull,  when  per- 
foration and.  traction  alone  are  insufficient  to  effect  delivery.  Many 
forms  of  craniotomy  forceps  are  in  use ;  some  armed  with  formidable 
teeth,  others,  of  simpler  construction,  depending  on  their  roughened 
and  serrated  internal  surfaces  for  firmness  of  grasp.  For  general 
use,  there  is  no  better  instrument  than  the  cranioclast  of  Sir  James 
Simpson  (Fig.  175),  which  admirably  fulfils  both  these  indications. 
It  consists  of  two  separate  blades,  fastened  by  a  button  joint.  The 
extremities  of  the  blades  are  of  a  duck-billed  shape,  and  are  suffi- 
ciently curved  to  allow  of  a  firm  grasp  of  the  skull  being  taken  ;  the 
upper  blade  is  deeply  grooved  to  allow  the  lower  to  sink  into  it,  and 
this  gives  the  instrument  great  power  in  fracturing  the  cranial  bones, 
when  that  is  found  to  be  necessary.  It  need  not,  however,  be  em- 
ployed for  the  latter  purpose,  and,  the  blades  being  serrated,  on  their 
under  surface,  form  as  perfect  a  pair  of  craniotomy  forceps  as  any  in 
ordinary  use.  Provided  with  it,  we  are  spared  the  necessity  of  pro- 
curino-  a  number  of  instruments  for  extraction. 


Fig.  174. 


Fig.  175. 


Craniotomy  Forceps. 


Simpson's  Cranioclast. 


Cephalotnbe. — Amongst  modern  improvements  in  midwifery  there 
are  few  which  have  led  to  more  discussion  than  the  use  of  the  cepha- 
lotrihe.  The  instrument,  originally  invented  by  Baudelocque,  was 
long  employed  on  the  Continent  before  it  was  used  in  this  country, 
the  prejudice  against  it  being  no  doubt  due  to  its  formidable  size  and 


OPERATIONS    INVOLVING    DESTRUCTION    OF    FOETUS.  495 

appearance.  Of  late  years  many  of  our  leading  obstetricians  have 
used  it  in  preference  either  to  the  crotchet  or  craniotomy  forceps,  and 
have  materially  mcjdified  and  improved  its  construction,  so  that  the 
most  objectionable  features  of  the  older  instruments  are  not  entirely 
removed. 

Object  of  the  Instrument. — -The  cephalotribe  consists  of  two  power- 
ful solid  blades,  which  are  applied  to  the  head  after  perforation,  and 
approximated  by  means  of  a  screw  so  as  to  crush  the  cranial  bones, 
and  after  this  it  may  be  also  used  for  extraction.  The  peculiar  value 
of  the  instrument  is,  that,  when  properly  applied,  it  crushes  the  firm 
basis  of  the  skull,  which  is  left  untouched  by  craniotomy,  or,  if  it 
does  not,  it  at  least  causes  the  base  to  turn  edgeways  within  the 
blades,  so  as  to  be  in  a  more  favorable  position  for  extraction.  An- 
other and  specially  valuable  property  is,  that  it  crushes  the  bones 
within  the  scalp,  wliich  forms  a  most  efficient  protective  covering  to 
their  sharp  edges  ;  in  this  way  one  of  the  principal  dangers  of  crani- 
otomy— the  wounding  of  the  maternal  passages  by  spiculfe  of  bone — 
is  entirely  avoided. 

The  cephalotribe,  therefore,  acts  in  two  ways  ;  as  a  crusher,  and 
as  a  tractor.  Some  obstetricians  believe  the  former  to  be  its  more 
important  use,  and  even  maintain  that  the  cephalotribe  is  unsuited 
for  traction.  This  view  is  specially  maintained  by  Pajot,  who  teaches 
that,  after  the  size  of  the  skull  has  been  diminished  by  repeated 
crushings,  its  expulsion  should  be  left  to  the  natural  powers.  There 
are  some  grounds  for  believing  that  in  the  greater  degrees  of  obstruc- 
tion the  tractile  power  of  the  instrument  should  not  be  called  into 
use ;  but,  in  the  large  majority  of  cases,  the  facility  with  which  the 
crushed  head  may  be  withdrawn  by  it  constitutes  one  of  its  chief 
claims  to  the  attention  of  the  obstetrician.  No  one  who  has  used  it 
in  this  way,  and  experienced  the  rapid  and  easy  manner  in  which  it 
accomplishes  delivery,  can  have  any  doubt  on  this  point. 

Its  Value. — There  is  every  reason  to  believe  that  cephalotripsy 
will  be  much  extended  in  this  country,  and  that  it  will  be  considered, 
as  I  believe  it  unquestionably  deserves  to  be,  the  ordinary  operation 
in  cases  requiring  destruction  of  the  foetus.  The  comparative  merits 
of  cephalotripsy  and  craniotomy  will  be  subsequently  considered. 

Description  of  the  Instrument. — -The  most  perfect  cephalotribe  is 
probably  that  known  as  Braxton  Hicks's  (Fig.  176),  which  is  a  modi- 
lication  of  Simpson's.  It  is  not  of  unwieldy  size,  but  sufficiently 
powerful  for  any  case,  and  not  extravagant  in  price.  The  blades 
have  a  slight  pelvic  curve,  which  materially  facilitates  their  intro- 
duction, yet  not  sufficiently  marked  to  interfere  with  their  being 
slightly  rotated  after  application.  Dr.  Kidd,  of  Dublin,  prefers  a 
straight  blade ;  while  Dr.  Matthews  Duncan  thinks  it  better  to  use 
a  somewhat  bulkier  instrument,  modelled  on  the  type  of  the  Conti- 
nental cephalotribes.  The  principle  of  action  of  all  these  is  identical 
and  their  differences  are  not  of  very  material  importance. 

Section  of  the  Skull  hy  the  I'^orceps-saw,  or  Ecraseiir. — -Another  mode 
of  diminishing  the  foetal  skull  is  by  removing  it  in  sections.    The  object 


496 


OBSTETRIC    OPERATIONS, 


Fig.  176.  is  aimed  at  in  the  forceps -satv  of  Van 

Pluevel,  which  consists  of  two  large 
blades,  not  unlike  those  of  the  cepha- 
lotribe  in  appearance.  Within  these 
there  is  a  complicated  mechanism, 
working  a  chain  saw  from  below  up- 
wards, which  cuts  through  the  foetal 
skull ;  the  separated  portions  are  sub- 
sequently withdrawn  piecemeal.  This 
instrument  is  highly  spoken  of  by  the 
Belgian  obstetricians,  who  believe  that 
it  affords  by  far  the  safest  and  most 
effectual  way  of  reducing  the  bulk  of 
the  foetal  skull.  In  this  country  it  is 
practically  unknown  ;  and^  although 
it  must  be  admitted  to  be  theoretic- 
ally excellent,  the  complexity  and 
cost  of  the  apparatus  have  always 
stood  in  the  way  of  its  being  used. 

Dr.  Barnes  has  suggested  that  the 
same  results  may  be  obtained  by 
dividing  the  head  with  a  strong  wire 
icraseur.  So  far  as  I  know,  this  sug- 
gestion has  never  yet  been  carried 
out  in  practice,  not  even  by  himself, 
and,  therefore,  it  is  not  possible  to  say 
mucii  about  it.  I  should  imagine, 
however,  that  there  would  be  consid- 
erable difficulty  in  satisfactorily  pass- 
ing the  loop  of  wire  over  the  skull, 
in  a  pelvis  in  which  there  is  any  well-marked  deformity. 

Cases  requiring  Craniotomy .■ — -The  most  common  cause  for  which 
craniotomy  or  cephalotripsy  is  performed,  is  a  want  of  proper  pro- 
portion between  the  head  and  the  maternal  passages.  This  may 
arise  from  a  variety  of  causes.  The  most  important,  and  that  most 
often  necessitating  the  operation,  is  osseous  deformit3^  This  may 
exist  either  in  the  brim,  cavity,  or  outlet,  and  it  is  most  often  met 
with  in  the  antero- posterior  diameter  of  the  brim.  Obstetric  au- 
thorities differ  considerably  as  to  the  precise  amount  of  contraction 
which  will  prevent  the  passage  of  a  living  child  at  term.  Thus 
Clarke  and  Burns  believe  that  a  living  child  cannot  pass  through  a 
pelvis  in  which  the  antero-posterior  diameter  at  the  brim  is  less  than 
3^  inches.  Ramsbotham  fixes  the  limit  at  3  inches,  and  Osborne  and 
Hamilton  at  2f  inches.  The  latter  is  the  extreme  limit  at  which  the 
birlli  of  a  living  child  is  possible;  but  there  can  be  no  doubt  that, 
under  favorable  circumstances,  it  may  be  possible  to  draw  the  foetus, 
after  turning,  through  a  pelvis  of  that  size.  The  opposite  limit  of 
the  operation  is  still  more  open  to  discussion.  Various  authorities 
have  considered  it  quite  possible  to  draw  a  mutilated  foetus  through 
a  pelvis  in  which  the  antero-posterior  diameter  does  not  exceed  IJ 


Hicks'a  Ceplialotribe. 


OPERATIONS  INVOLVING  DESTRUCTION  OF  F(ETUS.    407 

inches,  and,  indeed,  have  succeeded  in  doing  so.  But  then  there 
must  be  a  fair  amount  of  space  in  the  transverse  diameter  of  the 
pelvis  to  admit  of  tlie  necessary  manipulations.  If  there  be  a  clear 
space  here  of  3  inches  and  upwards,  it  is  no  doubt  possible  to  deliver 
•per  vias  naturales ;  but  in  such  extreme  deformities,  the  difficulties 
are  so  great,  and  the  bruising  of  the  maternal  structures  so  extensive, 
that  it  becomes  an  operation  of  the  greatest  possible  severity,  with 
results  nearly  as  unfavorable  to  the  mother  as  the  Ctesarean  section. 
Hence  some" Continental  authorities  have  not  scrupled  to  prefer  the 
latter  operation  in  the  worst  forms  of  pelvic  deformity.  The  rule  in 
English  practice  always  has  been  that  craniotomy  must  be  performed 
whenever  it  is  practicable;  and  there  can  be  no  doubt  that  it  is  the 
right  one.^ 

Limits  of  tlie  Operation. — Between  from  2f  to  3  inches  antero-pos- 
terior  diameter  in  the  one  direction,  and  If  inches  in  the  other,  may 
be  said  to  be  the  limits  of  craniotomy,  provided,  in  the  latter  case, 
there  be  a  fair  amount  of  space  in  the  transverse  diameter.  The 
same  limits  may  be  laid  down  with  regard  to  tumors  or  other  sources 
of  obstruction. 

Other  Causes  justifying  Craniotomy . — -Tliere  are  a  few  other  con- 
ditions in  which  craniotomy  is  justifiable,  independently  of  pelvic 
contraction,  such  as  certain  conditions  of  the  soft  parts  which  are 
supposed  to  render  the  passage  of  the  head  peculiarly  dangerous  to 
the  mother.  Among  them  may  be  mentioned  swelling  and  inflam- 
mation of  the  vagina  from  the  length  of  the  previous  labor,  bands 
and  cicatrices  in  the  vagina,  and  occlusion  and  rigidity  of  the  os.  It 
is  hardly  too  much  to  say  that  with  a  proper  use  of  the  resources  of 
midwifery,  the  destruction  of  a  living  foetus  for  any  of  these  condi- 
tions might  be  obviated.  The  most  common  of  them  is  undoubtedly 
swelling  of  the  soft  parts  causing  impaction  of  the  head ;  an  occur- 
rence which  ought  to  be  invariably  prevented  by  a  timely  use  of  the 
forceps.  Should  interference  unfortunately  be  delayed  until  impac- 
tion has  actually  taken  place,  doubtless  no  other  resource  but  crani- 
otomy would  be  left ;  but  such  cases,  it  is  to  be  hoped,  are  now  of 
rare  occurrence  in  British  practice.  Undue  rigidity  of  the  os  can  be 
overcome  by  dilatation  with  the  caoutchouc  bags,  or,  in  more  serious 
cases,  by  incision,  which  would  certainly  be  less  perilous  to  the 
mother  than  dragging  even  a  mutilated  foetus  through  the  small  and 
rigid  aperture.  In  the  case  of  bands  and  cicatrices  in  the  vagina, 
dilatation  or  incision  will  generally  suffice  to  remove  the  obstruction ; 
but  even  were  this  not  so,  here,  as  in  excessive  rigidity  of  the  peri- 
neum, it  would  be  better  that  slight  lacerations  should  take  place, 
than  that  the  child  should  be  killed. 

Complications  of  Labor  justifying  Craniotomy.- — Certain  complica- 
tions of  labor  are  held  to  justify  craniotomy,  such  as  rupture  of  the 
uterus,  convulsions,  and  hemorrhage.    The  application  of  the  forceps 

['  The  operation  may  be  practicable,  and  still  be  more  dangerous  than  the  Csesarean 
section.  Where  experience  shows  this  to  be  the  case,  we  should  in  the  United  States 
elect  the  latter  and  perform  it  early. — Harris's  note  to  2d  American  edition.] 


498  OBSTETRIC  OPERATIONS. 

or  turning  will  generally  answer  our  purpose  equally  well,  especially 
as  we  have  the  means  of  dilating  the  os  sufficiently  to  admit  of  one 
or  other  of  them  being  performed,  when  the  natural  dilatation  is  not 
sufficient.  Craniotomy  in  rupture  of  the  uterus  will  also  be  rarely 
indicated,  as  we  have  seen  that  gastrotomy  appears  to  aftbrd  a  better 
chance  to  the  mother  in  those  cases  in  which  the  foetus  has  partially 
or  entirely  escaped  from  the  uterine  cavity. 

Excessive  Size  of  the  Foetus. — Want  of  proportion  between  the 
foetus  and  the  pelvis,  depending  on  undue  size  of  the  head,  either 
natural,  or  the  result  of  disease,  may  render  the  operation  essential. 
In  the  former  of  these  cases  we  shall  generally  have  first  attempted 
delivery  with  the  forceps,  and,  if  it  has  failed,  there  can  be  no  doubt 
as  to  the  propriety  of  lessening  the  bulk  of  the  head  by  perforation. 

Craniotomy  when  the  Child  is  believed  to  he  Dead. — ^In  most  obstetric 
works  we  are  recommended  to  perforate,  rather  than  apply  the  for- 
ceps, when  we  are  convinced  that  the  child  has  ceased  to  live.  This 
advice  is  based  on  the  greater  facility  with  which  craniotomy  can 
be  performed,  and  its  supposed  greater  safety  to  the  mother.  There 
can  be  no  doubt  of  the  ease  with  which  the  child  can  be  extracted 
after  perforation,  when  the  pelvis  is  not  contracted  ;  and,  if  we  could 
always  be  sure  of  our  diagnosis,  the  rule  might  be  a  good  one.  Be- 
fore acting  on  it,  however,  we  must  bear  in  mind  the  extreme  diffii- 
culty  of  positively  ascertaining  the  death  of  the  foetus.  Of  the  signs 
usually  relied  on  for  this  purpose,  there  are  scarcely  any  which  are 
not  open  to  fallacy,  except  peeling  of  the  scalp,  and  disintegration 
of  the  cranial  bones  (which  do  not  take  place  unless  the  child  has 
been  dead  for  a  length  of  time),  and  they  are,  therefore,  useless,  in 
most  instances.  Discharge  of  the  meconium  constantly,  takes  place 
Avhen  the  child  is  alive ;  a  cold  and  pulseless  prolapsed  cord  may 
belong  to  a  twin  ;  and  the  foetal  heart  may  become  temporarily  inaud- 
ible, although  the  child  is  not  dead.  If,  indeed,  we  have  carefully 
watched  the  foetal  heart  all  through  the  labor,  and  heard  it  become 
more  and  more  feeble,  and  finally  stop  altogether,  we  might  be  cer- 
tain that  the  child  has  died  ;  but  surely  such  observations  Avould 
rather  indicate  an  early  recourse  to  the  forceps  or  version,  so  as  to 
obviate  the  fatal  result  we  know  to  be  impending. 

In  certain  breech  presentations,  or  after  turning,  it  may  be  found 
impossible  to  extract  the  head,  without  diminishing  its  size  by  per- 
forating behind  the  ear.  In  such  cases  we  know  to  a  certainty 
whether  the  child  be  alive  or  dead,  before  resorting  to  the  operation. 

The  first  step,  whether  we  resort  to  cephalotripsy  or  craniotomy, 
is  perforation,  which  will,  therefore,  be  first  described.  In  the  former 
the  desirability  of  first  perforating  the  head  is  not  always  recognized. 
To  endeavor  to  crush  the  head  without  perforating  is  needlessly 
to  increase  the  difliculties  of  the  case,  and  it  should  be  remembered, 
as  a  cardinal  rule,  that  perforation  is  an  essential  preliminary  to  the 
proper  use  of  the  cephalotribe. 

Metliod,  of  Perforation. — Before  perforating  we  must  carefully  as- 
certain the  exact  relation  of  the  os  to  the  presenting  part,  since,  in 


OPERATIONS    INVOLVING    DESTRUCTION    OF    FCETUS. 


499 


many  casos,  tlic  operation  is  per-  Fio.  177. 

formed  before  the  os  is  fully  di- 
lated, when  there  is  a  risic  of 
wounding  the  cervix.  Two  or 
more  fingers  of  the  left  hand 
should  be  passed  up  to  the  head, 
and  placed  against  the  most  promi- 
nent part  of  the  parietal  bone. 
Under  these,  used  as  a  guard  (Fig. 
177),  the  perforator  should  be  cau- 
tiously in  trod  need  until  the  scalp 
is  reached.  It  is  important  to  fix 
on  a  bony  part  of  the  skull,  and 
not  on  a  suture  or  fontanelle,  for 
puncture,  because  our  object  is  to 
break  up  the  vault  of  the  cranium 
as  much  as  possible,  so  as  to  allow 
the  skull  to  collapse.  When  the 
instrument  has  reached  the  point 
we  have  selected,  it  should  be  made 
to  penetrate  the  scalp  and  skull 
with  a  semi-rotatory  boring  mo- 
tion, and  advanced  until  it  has  sunk 
up  to  the  rests,  which  will  oppose 
its  further  progress.  Occasionally 
considerable  force  will  benecessary 
to  effect  penetration,  more  espe- 
cially if  the  scalp  be  swollen  by 
long-continued  pressure  ;  and  this 
stage  of  the  operation  will  be  facilitated  by  causing  an  assistant  to 
steady  the  head  by  pressure  on  the  foetus  through  the  abdomen  more 
especially  if  it  be  still  free  above  the  pelvic  brim.  We  must  then  press 
together  the  handles  of  the  instrument,  which  will  have  the  effect  of 
widely  separating  the  cutting  portion,  and  making  an  incision  through 
the  bones.  After  this  the  point  should  be  turned  round,  and  again 
opened  at  right  angles  to  the  former  incision,  so  as  to  make  a  free 
crucial  opening.  During  this  process  care  must  be  taken  to  bury 
the  perforator  in  the  skull  up  to  the  rests,  so  as  to  avoid  the  possi- 
bility of  injuring  the  maternal  soft  parts.  The  instrument  should 
now  be  introduced  within  the  skull  and  moved  freely  about,  so  as 
to  thoroughly  and  completely  break  up  the  brain.  Especial  care 
must  be  taken  to  reach  the  medulla  oblongata  and  base  of  the  brain, 
for,  if  these  were  not  destroyed,  w^e  might  subject  ourselves  to  the 
distress  of  extracting  a  child  in  whom  life  was  not  extinct.  If  this 
part  of  the  operation  be  thoroughly  performed,  there  will  be  no 
necessity  for  washing  out  the  brain  by  the  injection  of  warm  water 
as  is  sometimes  recommended,  for  the  broken-up  tissue  will  escape 
freely  through  the  opening  made  by  the  perforator. 

Perforation   of  the   After-coming  Head. — The    perforation  of  the 
after-coming  head  does  not  generally  offer  any  particular  difficulty. 


Perforation  of  the  SkuU. 


500  OBSTETRIC  OPERATIONS. 

It  is  accomplisliecl  in  the  same  manner,  the  child's  body  being  well 
drawn  out  of  the  way  by  an  assistant.  The  point  of  the  perforator, 
carefully  guarded  by  the  finger,  is  guided  up  to  the  occiput,  or  behind 
the  ear.  where  it  is  inserted. 

It  is  sometimes  useful  to  Postpone  Extraction. — If  there  be  no  neces- 
sity for  very  rapid  delivery,  and  the  pains  be  still  present,  it  is  often 
advisable  to  wait  ten  minutes  or  a  quarter  of  an  hour  before  pro- 
ceeding to  extract.  This  delay  will  allow  the  skull  to  collapse  and 
become  moulded  to  the  cavity  of  the  pelvis,  when  forced  down  by 
the  j^ains,  and  possibly  the  natural  efforts  may  suffice  to  finish  the 
Jabor  in  that  time  ;  or,  at  least,  the  head  will  have  descended  further, 
ani  will  be  in  a  better  position  for  extraction.  Should  perforation 
be  required  after  having  failed  to  deliver  with  the  forceps — and  this 
is  only  likely  to  be  ths  case  when  the  obstruction  is  comparatively 
slight — it  is  certainly  a  good  plan  to  perforate  without  removing  the 
forceps,  wdiich  may  then  be  used  as  tractors. 

We  have  now  to  decide  on  the  method  of  extraction,  and  our 
choice  lies  between  the  cephalotribe  and  the  craniotomy  forceps. 

Gom,parative  merits  of  Ge^ohalotripsy  and  Craniotomy. — Those  who 
have  used  both  must,  I  think,  admit  that  in  any  ordinary  case,  in 
wdiich  the  obstruction  is  not  great,  and  only  a  comparatively  slight 
diminution  in  the  size  of  the  head  is  required,  cephalotripsy  is  infi- 
nitely the  easier  operation.  The  facility  with  which  the  skull  can 
be  crushed  is  sometimes  remarkable,  and  those  who  will  take  the 
trouble  to  read  the  reports  of  the  operation  published  by  Braxton 
Hicks,  Kidd,  and  others,  cannot  fail  to  be  struck  with  the  rapidity 
w;ith  which  the  broken-down  head  may  often  be  extracted.  This  is 
far  from  being  the  case  with  the  craniotomy  forceps,  even  when  the 
obstruction  is  moderate  only  ;  for  it  may  be  necessary  to  use  consid- 
erable traction,  or  the  blades  may  take  a  proper  grasp  with  difficulty, 
or  it  may  be  essential  to  break  down  and  remove  a  considerable 
portion  of  the  vault  of  the  cranium  before  the  head  is  lessened  suffi- 
ciently to  pass.  During  the  latter  process,  however  carefully  per- 
formed, there  is  a  certain  risk  of  injuring  the  maternal  structures, 
and,  in  the  hands  of  a  nervous  or  inexperienced  operator,  this  dan- 
ger, whicli  is  entirely  avoided  in  cephalotripsy,  is  far  from  slight. 
The  passage  of  the  blades  of  the  cephalotribe  is  by  no  means  difficult, 
and  I  think  it  must  be  admitted  that  the  possible  risks  attending  it 
are  comparatively  small.  On  account,  therefore,  of  its  simplicity  and 
safety  to  their  maternal  structures,  I  believe  cephalotripsy  to  be  de- 
cidedly the  preferable  operation  in  all  cases  of  moderate  obstruction. 

When  we  approach  the  lower  limit,  and  have  to  do  with  a  very 
marked  amount  of  pelvic  deformity,  the  two  operations  stand  on  a 
more  equal  footing.  Then  the  deformity  may  be  so  great  as  to  render 
it  difficult  to  pass  the  blades  of  even  the  smallest  cephalotribe  suffi- 
ciently deep  to  grasp  the  head  firmly,  and,  even  when  they  are  passed, 
the  space  is  often  so  limited  as  to  impede  the  easy  working  of  the 
instrument.  Besides  this,  repeated  crushings  may  be  required  to 
diminish  the  skull  sufficiently.  I  attach  but  little  importance  to  the 
argument  that  the  diminution  of  the  skull  in  one  diameter  increases 


OPERATIONS    INVOLVING    DESTRUCTION    OF    FCETUS.  601 

its  bulk  in  another.  The  necessity  of  removing  and  replacing  the 
blades  on  another  part  of  the  skull,  and  of  repeating  tliis  perhaps 
several  times,  in  the  manner  recommended  by  Pajot,  is  a  far  more 
serious  objection.  To  do  this  in  a  contracted  pelvis  involves,  of 
necessity,  the  risk  of  much  contusion.  Fortunately  cases  of  this  kind 
are  of  extreme  rarity,  much  more  so  than  is  generally  believed,  but 
when  they  do  occur  they  tax  the  resources  of  the  practitioner  to  the 
utmost. 

On  the  whole,  the  conclusion  I  would  be  inclined  to  arrive  at  with 
regard  to  the  two  operations  is,  that  in  all  ordinary  cases,  cephalo- 
tripsy  is  safer  and  easier,  whereas  in  cases  with  considerable  pelvic 
deformity,  the  advantages  of  cephalotripsy  are  not  so  well  marked, 
and  craniotomy  may  even  prove  to  be  preferable. 

Description  of  the  Operation. — The  first  step  in  using  the  cephalo- 
tribe  is  the  passage  of  the  blades.  These  are  to  be  inserted  in  pre- 
cisely the  same  manner,  and  with  the  same  precautions  as  in  the 
high  forceps  operation.  In  many  cases  the  os  is  not  fully  dilated, 
and  it  is  absolutely  essential  to  pass  the  instrument  within  it.  Special 
care  should,  therefore,  be  taken  to  avoid  any  injury  to  its  edges,  and, 
for  this  purpose,  two  or  three  fingers  of  the  left  hand,  or  even  the 
whole  hand,  should  be  passed  high  up,  so  as  thoroughly  to  protect 
the  maternal  structures.  In  order  that  the  base  of  the  skull  maybe 
reached  and  effectually  crushed,  the  blades  must  be  deeply  inserted, 
and,  in  doing  this,  great  care  and  gentleness  must  be  used.  As  the 
projecting  promontory  of  the  sacrum  generally  tilts  the  head  for- 
wards, the  handles  of  the  instrument,  after  locking,  must  be  well 
pressed  back  towards  the  perineum.  If  the  blades  do  not  lock  easily, 
or  if  any  obstruction  to  their  passage  be  experienced,  one  of  them  must 
be  withdrawn  and  re-introduced,  just  as  in  forceps  operations.  Care 
must  be  taken,  as  the  instrument  is  being  inserted,  to  fix  and  steady 
the  head  by  abdominal  pressure,  since  it  is  generally  far  above  the 
brim,  and  would  readily  recede  if  this  precaution  were  neglected. 
When  the  blades  are  in  situ,  we  proceed  to  crush  by  turning  the 
screw  slowly,  and  as  the  blades  are  approximated,  the  bones  yield, 
and  the  cephalotribe  sinks  into  the  cranium.  The  crushed  portion 
then  measures  of  course,  no  more  than  the  thickness  of  the  blades, 
that  is  about  IJ  inches.  This  is  necessarily  accompanied  by  some 
bulging  of  the  part  of  the  cranium  that  is  not  within  the  grasp  of 
the  instrument  (Fig.  178),  but  in  slight  deformity  this  is  of  no  con- 
sequence, and  we  may  proceed  to  extraction,  waiting,  if  possible,  for 
a  pain,  and  drawing  downwards  in  the  axis  of  the  pelvic  outlet,  as 
in  forceps  delivery.  The  site  of  perforation  should  be  examined  to 
see  that  no  spicule  of  bone  are  projecting  from  it,  and  if  so  they 
should  be  carefully  removed.  In  such  cases  the  head  often  descends 
at  once,  and  with  the  greatest  ease.  Should  it  not  do  so,  or  should 
the  obstruction  be  considerable,  a  quarter  turn  should  be  given  to 
the  handles  of  the  instrument,  so  as  to  bring  the  crushed  portion  into' 
the  narrowed  diameter,  and  the  uncrushed  portion  into  the  wider 
transverse    diameter.      It   may  now   be   advisable    to   remove   the 


502 


OBSTETRIC    OPERATIONS, 


Fig.  its.  blades  carefully,  and  to  reintroduce  them 

with  the  same  precautions,  so  as  to  crusii 
the  unbroken  portion  of  the  skull.  This 
adds  materially  to  the  difficulties  of  the 
case,  since  the  blades  have  a  tendency  to 
fall  into  the  deep  channel  already  made 
in  the  cranium,  and  so  it  is  by  no  means 
always  easy  to  seize  the  skull  in  a  new 
direction.  Before  reapplying  them,  if  the 
condition  of  the  patient  be  good  and  pains 
be  present,  it  may  be  well  to  Avait  an  hour 
or  more,  in  the  hope  of  the  head  being 
moulded  and  pushed  down  into  the  pelvic 
cavity.  This  was  the  plan  adopted  by 
Dubois,  and,  according  to  Tarnier,  was 
u     .  the  secret  of  his  great  success  in  the  oper- 

1  *    1  ation.     Pajot's  method  of  repeated  crush - 

\  \l  l  ings,  in  the  greater  degrees  of  contraction, 

ill  is  based  on  the  same  idea,  and  he  recom- 

mends that  the  instrument  should  be  rein- 
troduced at  intervals  of  two,  three,  or  four 
hours,  according  to  the  state  of  the  patient, 
until  the  head  is  thoroughly  crushed;  no 
attempts  at  traction  being  used,  and  ex- 
pulsion being  left  to  the  natural  powers. 
This,  he  says,  should  always  be  done  when 
the  contraction  is  below  2J  inches,  and  he 
maintains  that  it  is  quite  possible  to  effect 
delivery  by  this  means  when  there  is  only 
1|  inches  in  the  antero-posterior  diameter. 
The  repeated  introduction  of  the  blades  in 
this  fashion  must  necessarily  be  hazardous,  except  in  the  hands  of  a 
very  skilful  operator ;  and  I  believe  that  if  a  second  application  fail 
to  overcome  the  difficulty,  which  will  only  be  very  exceptionally  the 
case,  that  it  would  be  better  to  resort  to  the  measures  presently  to 
be  described. 

Should  we  elect  to  trust  to  the  craniotomy  forceps  for  extraction, 
one  blade  is  to  be  introduced  through  the  perforation,  and  the  other, 
in  apposition  to  it,  on  the  outside  of  the  scalp.  In  moderate  deformi- 
ties, traction  applied  during  the  pains  may  of  itself  suffice  to  bring 
down  the  head.  Should  the  obstruction  be  too  great  to  admit  of 
this,  it  is  necessary  to  break  down  and  remove  the  vault  of  the 
cranium.  For  this  purpose  Simpson's  cranioclast  answers  better 
than  any  other  instrument.  One  of  the  blades  is  passed  within  the 
cranium,  the  other,  if  possible,  between  the  scalp  and  the  skull,  and 
the  portion  of  bone  grasped  between  them  is  then  broken  off';  this 
can  generally  be  accomplished  by  a  twisting  motion  of  the  wrist, 
without  using  much  force.  The  separated  portion  of  bone  is  then 
extracted,  the  greatest  care  being  taken  to  guard  the  maternal  struc- 


Foetal  Head  crushed  by  the 
Cephalotribe. 


OPERATIONS  INVOLVING  DESTRUCTION  OF  F(ETUS. 


i03 


tures,  during  its  removal,  by  the  fingers  of 
the  left  hand.  Tiie  instrument  is  then  applied 
to  a  fresh  part  of  the  skull,  and  the  same  pro- 
cess repeated,  until  as  much  of  the  vault  of 
the  cranium  as  may  be  necessary  is  broken 
up  and  removed. 

[The  craniotomy  forceps  chiefly  in  use  with 
us  were  devised  by  the  late  Prof.  Charles  D. 
Meigs,  for  his  second  operation  upon  Mrs. 
Eeybold,  of  Philadelphia,  in  1833,  and  have 
been  used  repeatedly  since,  either  as  tractors, 
or  for  reducing  the  size  of  the  foetal  head,  in 
cases  of  deformity  of  the  pelvis.^  Some  obste- 
tricians prefer  the  less  curved,  and  broader- 
bladed  instrument  of  Great  Britain,  as  a  trac- 
tor ;  but  for  the  general  purposes  of  picking 
away  the  cranial  bones,  and  drawing  down  the 
bass  of  the  skull,  in  cases  of  extreme  pelvic 
deformity,  there  is  no  more  simple  appliance 
than  that  of  Dr.  M3igs. 

To  act  upon  an  oval  body  like  the  foetal 
head.  Dr.  M.  was  obliged  to  prepare  two  forms 
of  forceps — straight  and  curved — to  be  used 
as  might  be  required,  according  to  the  part  of 
the  skull  to  be  broken  down,  or  drawn  upon, 
made,  serrated,  and  12|  inches  in  length. — Ed.] 

Advantages   of   hringing   down    the   Face   in    Difflcult 


Fig.  180. 


Straight 

Craniotoii  y 

Forceps. 


These  are  lightly 


Ca 


.—Dr. 


Braxton  Hicks^  has  conclusively  shown  that  in  difficult  cases,  after 
the  removal  of  the  cranial  vault,  the  proper  procedure  is  to  bring 
down  the  face ;  since  the  smallest  measurement  of  the  skull  after  the 
removal  of  the  upper  part  of  the  cranium,  is  from  the  orbital  ridge 
to  the  alveolar  edge  of  the  superior  maxillary  bone.  This  alteration 
in  the  presentation  he  proposes  to  effect  by  a  small  blunt  hook,  made 
for  the  purjDose,  which  is  forced  into  the  orbit,  by  means  of  which 
the  face  is  made  to  descend.  Barnes  recommends  that  this  should 
be  done  by  fixing  the  craniotomy  forceps  over  the  forehead  and  face, 
and  making  traction  in  a  backward  direction,  so  as  to  get  the  face 
past  the  projecting  promontory  of  the  sacrum.  The  importance  of 
bringing  down  the  face  was  long  ago  pointed  out  by  Burns,  but  it 
has  been  lost  sight  of,  until  Hicks  again  drew  attention  to  it  in  the 
paper  referred  to.  In  the  class  of  cases  in  which  this  procedure  is 
valuable,  the  risk  to  the  maternal  passages,  from  the  removal  of 
fractured  portions  of  bone,  must  always  be  considerable,  and  it  is  of 
great  importance  not  only  to  preserve  the  scalp  as  entire  as  possible, 
so  as  to  protect  them,  but  to  use  the  utmost  possible  care  in  removing 
the  broken  pieces  of  bone. 

Extraction  of  the  Body. — -When  the  extraction  of  the  head  has 


['  The  illustration  given  is  taken  from  the  instruments  devised  by  Dr.  Meigs  as 
an  improvement  upon  his  origiTial  pattern,  and  will  bo  seen  to  differ  from  that  here- 
tofore given  in  American  obstetrical  publications. — Ed.] 

2  Obst.  Trans.,  vol.  vii. 


50-1  OBSTETRIC    OPERATIONS. 

been  effected,  either  by  the  cephalotribe  or  the  craniotomy  forceps, 
there  is  seldom  much  difficulty  with  the  body.  By  traction  on  the 
head  one  of  the  axilliE  can  easily  be  brought  within  reach,  and  if  the 
body  do  not  readily  pass,  the  blunt  hook  should  be  introduced,  and 
traction  made  until  the  shoulder  is  delivered.  The  same  can  then  be 
done  with  the  other  arm.  If  there  be  still  difficulty,  the  cephalotribe 
may  be  used  to  crush  the  thorax.  The  body  is,  however,  so  com- 
pressible that  this  is  rarely  required. 

Embryotomy  where  Turning  is  Impossible. — There  only  remains  for 
us  to  consider  the  second  class  of  destructive  operations.  These  may 
be  necessary  in  long-neglected  cases  of  arm  presentation,  in  which 
turning  is  found  to  be  impracticable.  Here  fortunately  the  question 
of  killing  the  fcetus  does  not  arise,  since  it  will,  almost  necessarily, 
have  already  perished  from  the  continuous  pressure.  We  have  two 
operations  to  select  from,  decapitation  and  evisceration. 

Decapitation. — The  former  of  these  is  an  operation  of  great  an- 
tiquity, having  been  fully  described  by  Celsus.  It  consists  in  sever- 
ing the  neck,  so  as  to  separate  the  head  from  the  body ;  the  body  is 
then  withdrawn  by  .means  of  the  protruded  arm,  leaving  the  head  in 
utero  to  be  subsequentl}^  dealt  with.  If  the  neck  can  be  reached 
without  great  difficulty — and,  in  the  majority  of  cases,  the  shoulder 
is  sufficiently  pressed  down  into  the  pelvis  to  render  this  quite  possi- 
ble— there  can  be  no  doubt,  that  it  is  much  the  simpler  and  safer 
operation. 

Methods  of  dividing  the  Neck. — The  whole  question  rests  on  the 
possibility  of  dividing  the  neck.  For  this  purpose  many  instruments 
have  been  invented.  The  one  generally  recommended  in  this  country 
is  known  as  Eamsbotham's  hook,  and  consists  of  a  sharply  curved 
hook,  with  an  internal  cutting  edge.  This  is  guided  over  the  neck, 
which  is  divided  by  a  sawing  motion.  There  is  often  considerable 
difficulty  in  placing  the  instrument  over  the  neck,  although,  if  this 
were  done,  it  would  doubtless  answer  well.  Others  have  invented 
instruments,  based  on  the  principle  of  the  apparatus  for  plugging 
the  nostrils,  by  means  of  which  a  spring  is  passed  round  the  neck, 
and  to  the  extremity  of  the  spring  a  short  cord,  or  the  chain  of  an 
(^craseur,  is  attached ;  the  spring  is  then  withdrawn  and  brings  the 
chain  or  cord  into  position.  The  objection  to  any  of  these  appa- 
ratuses is,  that  they  are  unlikely  to  be  at  hand  when  required,  for 
few  practitioners  provide  themselves  with  costly  instruments  which 
they  may  never  require.  It  is  of  importance,  therefore,  that  we 
should  have  at  our  command  some  means  of  dividing  the  neck,  which 
is  available  in  the  absence  of  any  of  these  contrivances.  Dubois  re- 
commends for  this  purpose  a  strong  pair  of  bluut  scissors.  The  neck 
is  brought  as  low  as  possible  by  traction  on  the  prolapsed  arm,  and 
the  blades  of  the  scissors  guided  carefully  up  to  it.  By  series  of 
cautious  snipping  movements  it  is  then  completely  divided  from 
below  upwards.  This,  if  the  neck  be  readily  within  reach,  can  gen- 
erally be  cfiected  without  any  particular  difficult^^  Dr.  Kidd,  of 
Dublin,^  who  strongly  advocates  this  operation,  recommends  that  an 

1  Dublin  Quart.  Journ.,  May,  1871, 


OPERATIONS    INVOLVING    DESTllUCTION    OF    FOiTUS.  605 

ordinary  male  clastic  catlicter,  strongly  curved  and  mounted  on  a  firm 
stilet,  or,  still  better,  on  a  uterine  sound,  should  be  passed  round  the 
neck.  Previous  to  introduction  a  cord  should  be  attached  to  the  ex- 
tremity of  the  catheter,  which  is  left  round  the  neck  when  it  is  with- 
drawn. By  means  of  this  cord  a  strong  piece  of  whipcord,  or  the 
wire  of  an  ^ciraseur,  can  easily  be  drawn  round  the  neck  and  used 
for  dividing  it.  The  former,  to  protect  the  maternal  structures, 
may  be  worked  through  a  speculum,  and  by  a  series  of  lateral 
movements  the  neck  is  easily  severed.  The  ^craseur,  however,  offers 
special  advantages,  since  it  entirely  does  away  with  any  risk  of  in- 
juring the  mother. 

Withdraioal  of  the  Body  and  Delivery  of  the  Head. — After  the  neck 
is  divided  the  remainder  of  the  operation  is  easy.  The  body  is 
withdrawn  without  difficulty  by  the  arm,  and  we  then  proceed  to 
deliver  the  head.  By  abdominal  pressure  this,  in  most  cases,  can  be 
pushed  down  into  the  pelvis,  so  as  to  come  easily  within  reacli  of 
the  cephalotribe,  which  is  by  far  the  best  instrument  for  extraction. 
Preliminary  perforation  is  not  necessary,  since  the  brain  can  escape 
through  the  severed  vertebral  canal.  The  secret  of  doing  this  easily 
is  to  li.x  and  press  down  the  head  sufficiently  from  above,  otherwise 
it  woidd  slip  away  from  the  grasp  of  the  instrument.  The  perfora- 
tor and  craniotomy  forceps  may  be  used,  if  the  cephalotribe  be  not 
at  hand.  Perforation  is,  liowever,  by  no  means  always  easy,  on  ac- 
count of  the  mobility  of  the  head.  After  it  is  accomplished  one 
blade  of  the  craniotomy  forceps  is  passed  within  the  skull,  the  other 
externally,  and  the  head  slowly  drawn  down. 

Evisceration. — The  alternative  operation  of  evisceration  is  a  much 
more  troublesome  and  tedious  procedure,  and  should  only  be  used 
when  the  neck  is  inaccessible.  The  first  step  is  to  perforate  the 
thorax  at  its  most  depending  part,  and  to  make  as  wide  an  opening 
into  it  as  possible,  in  order  to  gain  access  to  its  contents.  Through 
this  the  thoracic  viscera  are  removed  piecemeal,  being  first  broken 
up  as  much  as  possible  by  the  perforator,  and  then,  the  diaphragm 
being  penetrated,  those  in  the  abdomen.  The  object  is  to  allow  the 
body  to  collapse,  and  the  pelvic  extremities  to  descend,  as  in  sponta- 
neous evolution.  This  can  be  much  facilitated  by  dividing  the  spinal 
column  with  a  strong  pair  of  scissors,  introduced  into  the  opening 
made  in  the  thorax,  so  that  the  body  may  be  doubled  up  as  on  a 
hinge.  Here  the  crotchet  may  find  a  useful  application,  for  it  can 
be  passed  through  the  abdominal  cavity,  and  fixed  on  some  point  in 
the  interior  of  the  child's  pelvis ;  and  thus  strong  traction  can  be 
made  without  any  risk  of  injury  to  the  mother.  It  can  be  readily 
understood  that  this  process  is  so  lengthy  and  difficult  as  to  render 
it  probably  the  most  trying  of  obstetric  operations ;  it  is  certainly 
inferior  in  every  respect  to  decapitation,  and  is  only  to  be  resorted 
to  when  that  is  impracticable.^ 

['  In  nine  instances  of  impaction  of  the  fostus  in  a  transverse  position,  in  the  United 
States,  the  CcTesarean  operation  has  been  performed,  owing  to  great  difficulty  in  accom- 
plishing either  decapitation  or  evisceration,  and  six  of  the  women  were  saved.     The 
three  deaths  were  from  exhaustion. — Ed.] 
33 


506  OBSTETRIC  OPERATIONS. 


CHAPTER   YI. 

THE  CiESAREAN"  SECTION — SYMPHYSEOTOMY — AND  LAPAEO- 
ELYTROTOMY. 

History. — The  Cassarean  section  has  perhaps  given  rise  to  more 
discussion  than  any  other  subject  connected  with  midwifery,  and 
there  is  yet  much  difi'erence  of  opinion  as  to  the  limits  of,  and  indica- 
tions for,  the  operation.  The  period  at  which  the  Ctesarean  section 
was  first  resorted  to  is  not  known  with  accuracy.  It  seems  to  have 
been  practised  by  the  Greeks,  after  the  death  of  the  mother ;  and 
Pliny  mentions  that  Scipio  Africanus  and  Manlius  were  born  in  this 
way.  The  name  of  Csesar  is  said  to  have  been  given  to  children  so 
extracted,  and  afterwards  to  have  been  assumed  as  a  family  patro- 
nymic. These  children  were  dedicated  to  Apollo ;  whence  arose  the 
practice  of  things  sacred  to  that  god  being  taken  under  the  special 
protection  of  the  family  of  the  Caesars.  Many  celebrities  have  been 
supposed  to  owe  their  lives  to  the  operation  ;  among  the  rest  J5scula- 
pius,  Julius  Cassar,  and  our  own  Edward  VI.  Regarding  the  two 
latter,  there  is  conclusive  proof  that  the  tradition  is  without  founda- 
tion. There  is  no  doubt  that  the  operation  was  constantly  practised 
on  women  who  had  died  at  an  advanced  period  of  pregnancy,  and 
indeed  it  has,  at  various  times,  been  enforced  by  law.  Thus  among 
the  Romans  it  was  decreed  by  Numa,  that  no  pregnant  woman  should 
be  buried  until  the  foetus  had  been  removed  by  abdominal  section. 
The  Italian  laws  also  made  it  necessary,  and  the  operation  has 
always  received  the  strong  support  of  the  Roman  Church.  So  lately 
as  the  middle  of  the  eighteenth  century,  the  King  of  Sicily  sentenced 
to  death  a  physician  who  had  neglected  to  practise  it.  The  first 
authentic  case  in  which  the  operation  was  performed  on  a  living 
Avoman  occurred  in  1-191.  It  was  afterwards  practised  by  Nufer  in 
1500;  and  in  1581  Rousset  published  a  work  on  the  subject,  in  which 
a  number  of  successful  cases  were  related.  In  English  works  of  that 
time  it  is  not  alluded  to,  although  it  was  undoubtedly  performed  on 
the  Continent,  and  to  such  an  extent  that  its  abuse  became  almost 
proverbial.  We  have  evidence  in  Shakespeare,  however,  that  the 
operation  was  familiarl}^  known  in  this  country,  since  he  tells  us 
that — 

.     .     .     .     Macduff  was  from  his  mother's  womb 
Untimely  ripped. 

Par^  and  Guillemeau,  amongst  the  writers  of  the  period,  were  noted 
for  their  hostility  to  the  operation,  while  others  equally  strongly 
upheld  it. 

In  this  country  it  has  scarcely  ever  been  performed  in  a  manner 


CESAREAN    SECTION.  507 

wliicli  offers  even  the  faintest  liope  of  success.  It  has  been  looked 
upon  as  almost  necessarily  fatal  to  the  mother,  and  it  has,  therefore, 
been  delayed  until  the  patient  has  arrived  at  the  utmost  stage  of 
exhaustion.  For  example,  in  looking  over  the  records  of  British 
cases,  it  is  no  uncommon  thing  to  find  that  the  Caesareau  section  was 
resorted  to,  two,  three,  or  even  six  days  after  labor  had  begun,^  and 
when  the  patient  was  almost  moribund.  With  rare  exceptions  within 
the  last  few  years,  the  operation  has  been  performed  in  what  may  be 
called  a  hap- hazard  way.  In  many  cases  long  and  fruitless  attempts 
at  delivery  by  craniotomy  had  already  been  made,  so  that  the  pas- 
sages had  been  subjected  to  much  contusion  and  violence.  Little  or 
no  attempt  has  been  made  to  obviate  the  well-known  risks  of  ab- 
dominal operations;  no  care  has  been  taken  to  prevent  blood  and 
other  fluids  finding  their  way  into  the  peritoneal  cavity,  and  no 
means  have  been  adopted  subsequently  to  remove  them.  It  is, 
therefore,  not  so  much  a  matter  of  surprise  that  the  mortality  has 
been  so  great,  but  rather  that  any  cases  have  recovered. 

Mortality .—Evom.  what  we  know  of  the  history  of  ovariotomy,  its 
early  fatality,  and  the  extreme  and  even  apparently  exaggerated 
precautions  which  are  essential  to  its  success,  it  is  fair  to  conclude 
that,  if  the  Cassarean  section  were  performed,  as  it  is  to  be  hoped  it 
always  will  be  in  future,  with  the  same  careful  attention  to  minute 
details  as  ovariotomy,  the  results  would  not  be  so  disastrous.  Making 
every  allowance  for  these  facts,  it  must  be  admitted  that  the  Csesa- 
rean  section  is  necessarily  almost  a  forlorn  hope;  and  in  making 
these  observations  I  have  no  intention  of  contesting  the  well-estab- 
lished rule  of  British  practice,  that  it  is  not  admissible  as  an  opera- 
tion of  election,  and  must  only  be  resorted  to  when  delivery  ^^er  vias 
naturales  is  impossible. 

Statistical  Returns  are  tiot  Reliahle. — The  mortality,  as  given  in 
statistical  returns  from  various  sources,  differs  so  greatly  as  to  make 
them  but  little  reliable.  Badford  tabulates  77  operations  performed 
in  this  country,  of  which  QQ,  or  85.71  per  cent.,  proved  fatal,  and  11, 
or  14.28  per  cent.,  recovered.  Michaelis  and  Kayser  found  that  out 
of  258  and  338  operations,  54  and  64  per  cent,  respectively  were 
fatal.  These  include  operations  performed  under  all  sorts  of  condi- 
tions, even  when  the  patient  was  almost  moribund ;  and  until  we  are 
in  possession  of  a  sufficient  number  of  cases  performed  under  con- 
ditions showing  that  the  result  is  obviously  due  to  the  operation— 
in  which  it  was  undertaken  at  an  early  period  of  labor,  and  performed 
with  a  reasonable  amount  of  care- — -it  is  obviously  impossible  to  arrive 
at  any  reliable  conclusions  as  to  the  mortality  of  the  operation.^  That 
it  is  necessarily  hopeless  is  certainly  not  the  case,  and  we  know  that 
on  the  Continent,  where  it  is  resorted  to  much  oftener  and  earlier  iit 
labor  than  in  this  country,  there  are  authentic  cases  in  which  it  has 
been  performed  twice,  thrice,  and  even,  in  one  instance,  four  times 
on  the  same  patient.     Kayser  thinks  that  a  second  operation  on  the 

'  See  Radford  on  Csesarean  Section,  p.  15. 

[2  See  American  Statistics,  by  the  editor,  p.  522.] 


508  OBSTETRIC  OPERATIONS. 

same  patient  affords  a  better  prognosis  than  a  first,  probably  because 
peritoneal  adhesions,  resulting  from  the  first  operation,  have  shut  off* 
the  general  abdominal  cavity  from  the  uterine  wound ;  and  he  believes 
that  in  second  operations  the  mortality  is  not  more  than  29  per  cent. 

[The  Cxsarean  Operation  in  the  United  Kingdom. — It  is  impossible 
to  state  with  any  satisfactory  degree  of  accuracy,  how  many  times 
the  operation  has  been  performed  in  England,  Ireland,  and  Scotland  ; 
for  the  statistics  collected  are  with  very  few  exceptions  confined  to 
the  cases  that  have  been  published,  when  we  know  that  there  must 
be  many  that  have  never  appeared  in  print.  If  48  out  of  112  in  our 
own  country  were  not  reported  through  the  medical  journals  it  is 
not  at  all  likely  that  nine  will  cover  this  class  of  cases  in  Great 
Britain. 

Dr.  Thomas  Eadford,  of  Manchester,  continuing  and  embracing 
the  work  of  Dr.  Hull,  published  two  sets  of  tables,  one  in  1865,  con- 
taining the  records  of  77  operations ;  and  another  in  1868,  with  21 
additional  cases,  making  in  all  98.  Of  this  number,  82  died,  and 
only  16  recovered :  46  women  were  deformed  by  osteomalacia,  and 
16  by  rickets.  Several  British  authors,  one  even  residing  in  Man- 
chester, appear  not  to  be  aware  of  the  fact,  that  Dr.  Eadford  issued 
the  supplementary  pamphlet,  of  which  I  am  the  fortunate  possessor 
of  a  copy. 

Taking  up  the  record  where  Dr.  Eadford  left  it,  I  have  added  20 
more  operations  as  the  result  of  the  work  of  the  last  decade,  with  a 
favorable  issue  in  six  cases,  or  the  same  number  saved  as  in  the  pre- 
vious period  of  the  same  length.  It  may  be  that  I  have  failecl  to 
secure  several  cases,  as  there  were  thirty  collected  by  Dr.  Eadford 
for  the  previous  decade,  although  it  is  true  that  only  seventeen  were 
found  for  the  ten  years  ending  with  1858.  Of  the  118  cases  22  sur- 
vived, and  96  died.  That  is,  12  saved  out  of  50,  in  the  last  twenty 
years,  against  10  out  of  68  in  the  preceding  120  years,  which  is  some- 
what of  an  improvement  in  the  results  attained,  provided  we  have 
all  the  cases. 

Of  the  recovered  cases,  5  had  malignant  disease  of  the  cervix  nteri, 
6  pelvic  obstruction  from  osteomalacia,  5  ditto  from  rickets,  1  ditto 
from  fracture,  2  from  pelvic  exostosis,  and  1  from  coxalgic  anchylosis 
and  spinal  curvature.  One  woman  had  her  uterus  erroneously  punc- 
tured in  an  operation  of  ovariotomy,  and  in  one  the  cause  of  difficulty 
is  not  stated,  =  22. 

The  time  in  labor  of  the  22  cases  was  as  follows,  viz. :  Within 
twenty-four  hours,  5  ;  on  the  second  day,  4 ;  on  the  third  day,  5  ; 
four  clays,  1 ;  five  days,  1 ;  six  days,  1 ;  twelve  days,  1 ;  labor  not 
yet  commenced,  2  ;  and  not  stated,  2,  =  22. 

.  Dr.  Eadford  gives  56  as  the  number  of  children  ^^ preserved,''''  but 
■niis  includes  many  that  must  have  died  within  a  very  short  period. 
Of  the  20  cases  in  my  supplement,  the  children  were  living  in  12. 
Of  these,  2  died  in  a  few  moments,  1  lived  four  hours,  1  nine  days, 
1  seven  months,  and  1  seven  and  a  half  months,  so  that  but  6  appear 
as  having  lived  to  a  later  period.  One-half  of  the  children  were 
dead  when  removed  from  the  six  women  who  recovered  in  the  past 


CiESARBAN    SECTION.  509 

ten  years.  In  tlie  avIioIo  22  successful  operations,  15  children  were 
removed  alive,  of  whom  2  died  in  a  few  moments,  leaving  13  to  be 
counted  as  "  saved."  In  the  whole  118  operations,  about  one  in  five 
may  be  said  to  have  been  performed  in  a  reasonably  good  season. 

With  the  best  of  care  in  England,  the  success  in  the  operation 
must  always  bo  below  that  in  the  United  States,  provided  our  own 
subjects  are  promptly  subjected  to  the  knife.  This  is  shown  by  a 
comparison  between  the  timely  operations  of  the  two  countries. 
I  have  selected  out  21  British  cases,  recorded  as  follows :  in  3,  labor 
was  artificially  induced;  3  are  denominated  simply  as  "ear??/,"  and 
in  15,  tlie  pains  had  lasted  from  three  or  four  hours  to  thirteen. 
These  21  cases,  therefore,  may  be  classed  as  "early;"  and  notwith- 
standing the  measure  of  promptness,  but  5  recovered,  or  less  than 
the  proportion  of  the  published  cases  of  all  grades,  for  the  past  ten 
years.  Take  the  same  number  of  operations  performed  in  the  United 
States  within  the  same  measure  of  time,  and  we  may  reverse  the 
figures  of  saved  and  lost. 

It  is  no  wonder  then,  that  English  obstetricians  regard  the  Cassar- 
ean  operation  as  the  "  last  resort^''''  the  '■''forlorn  hope^''^  etc.,  and  turn 
their  attention  to  devising  all  kinds  of  expedients  where  possible  to 
avoid  the  necessity  for  its  performance.  Now,  while  I  have  every 
respect  for  British  opinion  in  matters  of  surgery,  I  do  not  wish  our 
own  obstetricians  and  surgeons  to  form  their  opinion  of  the  risks  of 
this  particular  operation  from  English  obstetrical  Avorks,  which  are 
correct  according  to  their  own  experience,  but  all  wrong  in  the  light 
of  American  success.  We  have  of  late  been  following  too  much  in 
the  line  of  their  opinion,  and  as  a  consequence  have  postponed  the 
use  of  the  knife  until  too  late  to  employ  it  except  with  fatal  effect. 

Promptness  in  action,  then,  does  not  appear  to  have  much  influence 
over  the  result  in  Great  Britain,  although  all  important  and  cjuite 
encouraging  here — for  of  six  earlj?-  British  cases  in  the  last  ten  years, 
with  the  greatest  care  in  management,  but  one  was  saved.  I  attri- 
bute this  difference  to  the  great  poverty  and  consequent  want  of 
stamina  in  the  subjects  operated  upon,  the  injurious  effects  npon 
their  tissues,  of  the  use  of  malt  drinks,  and  the  vomiting  and  uterine 
inertia  produced  by  inhaling  chloroform  when  administered  to  such 
subjects.  The  remarkable  results  of  ovariotomy  under  Spencer  Wells, 
Keith,  and  others,  show  that  it  is  largely  the  character  of  the  subject 
that  makes  the  Cassarean  section  so  much  more  dangerous ;  for,  al- 
though some  of  the  ovarian  cases  may  belong  to  the  same  impover- 
ished class,  the  great  majority  do  not,  and,  besides,  there  is  generally 
an  opportunity  of  improving  their  condition  by  proper  hygienic  and 
dietetic  treatment  preparatory  to  the  operation,  which  is  very  rarely 
the  case  with  reference  to  the  subjects  for  gastro-hysterotomy,  who 
must  endure  the  operation  while  still  nnder  the  depressing  effects  of 
poverty,  exposure  to  dampness,  and  it  may  be,  disease  resulting  from 
it  in  the  form  of  pelvic  softening,  an  affection  which  we  never  see  in 
our  native  population. — Ed.] 

Results  to  the  CJiild. — The  mortality  of  the  children  likewise  cannot 
be  ascertained  from  statistical  returns  since,  in  the  large  majority  of 


510  OBSTETRIC  OPERATIONS. 

cases  in  wliicli  dead  children  were  extracted,  tlie  result  had  nothing 
to  do  with  the  operation.  Indeed,  there  is  nothing  in  the  operation 
itself  which  can  reasonably  be  supposed  to  affect  the  child.  If,  there- 
fore, the  child  be  alive  when  the  operation  is  commenced,  there  is 
every  probabilitv  of  its  being  extracted  alive  ;  and  Eadford's  conclu- 
sion that,  "  the  risk  to  infants  in  Cesarean  births  is  not  much  greater 
than  that  which  is  contingent  on  natural  labor,  provided  correct  prin- 
ciples of  practice  are  adopted,"  probably  very  nearly  represents  the 
truth. 

Causes  requiring  the  Operation. — The  Csesarean  section  is  required 
when  there  is  such  defective  proportion  between  the  child  and  the 
maternal  passages,  that  even  a  mutilated  foetus  cannot  be  extracted. 
This  in  by  far  the  greatest  number  of  cases  is  due  to  deformity  of 
the  pelvis  arising  from  rickets  or  mollitis  ossium.  The  latter  may 
occur  in  a  patient  who  had  been  previously  healthy,  and  who  has 
given  birth  to  living  children.  It  is  a  more  common  cause  of  the 
extreme  varieties  of  deformity  than  rickets,  and  out  of  77  British 
cases,  tabulated  by  Eadford,  in  43  the  deformity  was  produced  by 
osteomalacia  and  in  l-i  only  by  rickets.  In  certain  cases  the  pelvis 
itself  may  be  of  normal  size,  but  has  its  cavity  obstructed  by  a  solid 
tumor  of  the  ovary,  of  the  uterus  itself,  or  one  growing  from  the 
pelvic  wall.  The  obstruction  may  also  depend  on  morbid  conditions 
of  the  maternal  soft  parts,  of  which  the  most  common  is  advanced 
malignant  disease  of  the  cervix.  Other  conditions  may,  however, 
render  it  essential.  Thus  Dr.  JSTewman^  records  a  case  in  which  he 
performed  the  operation  for  insurmountable  resistance  and  obstruc- 
tion of  the  cervix,  which  was  believed  at  the  time  to  be  malignant. 
The  patient  recovered,  and  was  subsequently  delivered  naturally, 
and  without  anything  abnormal  being  made  out.  This  renders  it 
probable  that  the  disease  was  not  malignant,  and  it  may  possibly 
have  been  an  extensive  inflammatory  exudatory  into  the  tissues  of 
the  cervix,  subsequently  absorbed.  I  myself  was  present  at  a  Csesar- 
ean  section  performed  in  Calcutta  in  the  year  1857,  when  the  pelvis 
was  so  uniformly  blocked  up  with  exudation,  probably  due  to  exten- 
sive pelvic  cellulitis  or  hsematocele,  that  the  operation  was  essential. 

Limits  of  Obstruction  justifying  the  Operation.- — Different  accou- 
cheurs have  fixed  on  various  limits  for  the  operation.  Most  British 
authorities  are  of  opinion  that  it  need  not  be  resorted  to,  if  the 
smallest  diameter  of  the  pelvis  exceed  1|  inch.^  This  question  has 
already  been  considered  in  discussing  craniotomy,  and  it  has  been 
shown  that  a  mutilated  foetus  may  be  drawn  through  a  pelvis  of  IJ 
inch  antero-posterior  diameter,  provided  there  be  a  space  of  3  inches 
in  the  transverse  diameter.  If  sufficient  space  for  using  the  neces- 
sary instruments  do  not  exist,  the  Cesarean  section  may  be  required, 
even  when  there  is  a  larger  antero-posterior  diameter  than  1|  inch. 
This  is  especially  likely  to  occur  when  we  have  to  do  with  deformity 

1  Obst.  Trans.,  vol.  iii.  p.  343. 

[2  In  Dr.  Parry's  table  of  70  craniotomies,  there  are  34  cases  of  2  to  2i  inches  con- 
jugate, and  still  the  mortality  (27)  amounts  to  37|^  per  cent.  Am.  Journ.  Obstetrics, 
N.  Y.  vol.  V.  1873,  p.  644.] 


CyESAKEAN    SECTION.  611 

arising  from  mollitics  ossium,  in  which  the  obstruction  is  in  the 
sides  and  outlet  of  the  pelvis,  the  true  conjugate  being  sometimes 
even  elongated.  On  the  Continent  the  Caesarean  section  is  constantly 
practised,  as  an  operation  of  election,  when  the  smallest  diameter 
measures  from.  2  to  2 J  inches;  and  when  the  child  is  known  to  be 
alive,  some  foreign  authors  recommend  it  when  there  are  as  much 
as  3  inches  in  the  antero- posterior  diameter.  In  this  countrj^,  where 
the  life  of  the  child  is  most  properly  considered  of  secondary  import- 
ance to  the  safety  of  the  mother,  we  cannot  fix  one  limit  for  the  ope- 
ration when  the  child  is  living,  and  another  when  it  is  dead.  Nor,  I 
think,  can  we  admit  the  desire  of  the  mother  to  run  the  risk,  rather 
than  sacrifice  the  child,  as  a  justification  of  the  operation,  although 
this  is  laid  down  as  an  indication  by  Schroeder.^  Great  as  are  the 
dangers  attending  craniotomy  in  extreme  deformity,  there  can  be  no 
doubt  that  we  must  perform  it  whenever  it  is  practicable,  and  only 
resort  to  the  Ca3sarean  section  when  no  other  means  of  delivery  are 
possible. 

For  this  reason  I  think  it  unnecessary  to  discuss  the  question, 
whether  we  are  justified  in  destroyiiig  the  foetus  in  several  successive 
pregnancies,  when  the  mother  knows  that  it  is  impossible  for  her  to 
give  birth  to  a  living  child,  Denman  was  the  first  to  question  the 
advisability  of  repeating  craniotomy  on  the  same  patient.  Amongst 
modern  authors  Eadford  takes  the  most  decided  view  on  this  point, 
and  distinctly  teaches  that  even  when  delivery  by  craniotomy  is  pos- 
sible, it  "can  be  justified  on  no  principle,  and  is  only  sanctioned  by 
the  dogma  of  the  schools,  or  by  usage,"  and  that,  therefore,  the 
Ci^sarean  section  should  be  performed  with  the  view  of  saving  the 
child.  Doubtless  much  can  be  said  from  this  point  of  view ;  but, 
nevertheless,  he  would  be  a  bold  man  who  would  deliberately  ©lect 
to  perform  the  Caesarean  section  on  such  grounds.^  It  is  to  be  hoped, 
however,  that  in  these  days  the  induction  of  premature  labor  or 
abortion  would  always  spare  us  the  necessity  of  deciding  so  delicate 
a  point. 

Post-mortem  Gsesarean  Operation. — The  Caesarean  section  may  also 
be  required  in  cases  in  which  death  has  occurred  during  pregnancy 
or  labor.  This  was  the  indication  for  which  it  was  first  employed, 
and  it  has  constantly  been  performed  when  a  pregnant  woman  has 
died  at  an  advanced  period  of  utero-gestation.  There  is  no  doubt 
that  a  prompt  extraction  of  the  child  under  these  circumstances  has 
frequently  been  the  means  of  saving  its  life,  but  by  no  means  so  often 
as  is  generally  supposed.  Thus  Schwartz^  showed  that  out  of  107 
cases  not  one  living  child  was  extracted.  Duer^  has  written  an  inte- 
resting paper  on  this  subject  in  which  he  has  tabulated  55  cases  of 

•    Manual  of  Midwifery,  p.  202. 

[2  This  was  done  twice  successfully  by  Prof.  William  Gibson  in  the  case  of  Mrs. 
Reybold,  of  Philadelphia,  in  1835,  and  1837,  after  she  had  twice  been  delivered  by 
craniotomy  under  Prof.  Charles  D.  Meigs,  who  declined  destroying  any  more  children 
for  her.  Mrs.  R.  still  lives  at  the  age  of  70,  and  the  daughter  and  son  likewise,  with 
their  six  children. — Ed.] 

3  Monat.  f.  Geburt.,  suppl.  vol.,  1861,  p.  121. 

■^  Post-mortem  Delivery,  Am.  Journ.  of  Obst.,  Jan.  1879. 


512  OBSTETRIC  OPERATIONS. 

post-mortem  Coesarean  section.  In  40  a  Uvinrj  child,  was  extracted, 
the  time  elapsing  after  the  death  of  the  mother  being  as  follows: 
"Between  1  and  5  minutes,  including  'immediately,'  and  'in  a  few 
minutes,'  there  were  21  cases;  between  5  and  10  minutes,  none; 
between  10  and  15  minutes,  13  cases;  between  15  and  23  minutes, 
2  cases ;  after  1  hour,  2  cases;  and  after  2  hours,  2  cases,"  In  those 
extracted,  however,  after  the  lapse  of  an  hour,  the  children  did  not 
ultimately  survive,  and  the  cases  themselves  seem  open  to  some 
doubt. 

Want  of  Success  in  Post-mortem  Operation. — The  reason  that  the 
want  of  success  has  been  so  great,  is  doubtless  the  delay  that  must 
necessarily  occur  before  the  operation  is  resorted  to,  for,  inde- 
pendently of  the  fact  that  the  practitioner  is  seldom  at  hand  at  the 
moment  of  death,  the  very  time  necessary  to  assure  ourselves  that 
life  is  actually  extinct  will  generally  be  sufficient  to  cause  the  death 
of  the  foetus.  Considering  the  intimate  relations  between  the  mother 
and  child,  we  can  scarcely  expect  vitality  to  remain  in  the  latter 
more  than  a  quarter,  or  at  the  outside,  half  an  hour,  after  it  has 
ceased  in  the  former.  The  recorded  instances  in  which  a  living  child 
was  extracted  ten,  twelve,  and  even  forty  hours  after  death,  were 
most  probably  cases  in  which  the  mother  fell  into  a  prolonged  trance 
or  swoon,  during  the  continuance  of  which  the  child  must  have  been 
removed,  A  few  authentic  cases,  however,  are  known  in  which 
there  can  be  no  reasonable  doubt  that  the  operation  was  performed 
successfully  several  hours  after  the  mother  was  actually  dead.  An 
often-quoted  and  interesting  example  is  that  of  the  Princess  of 
Schwartzenburgh,  who  perished  one  evening  in  a  fire  at  Paris,  and 
from  whose  body  a  living  infant  is  said  to  have  been  removed  on  the 
morning  of  the  following  day.  The  au.thenticity  of  this  case,  however, 
is  open  to  grave  doubt.^ 

\_Tlie  Story  of  the  Princess  of  Sclnvarzenherg  is  based  upon  the 
authority  of  Prof.  Gardien,  of  Paris,  who  introduced  it  into  his  work 
on  obstetrics  in  1816,  and  Prof.  Velpeau,  who  quotes  him  in  his  own 
in  1829  ;  and  this  is  all  the  authenticity  it  ever  had.  The  statement 
is  not  even  "open  to  a  grave  doubt,"  for  it  is  the  purest  of  all  fabri- 
cations, as  I  can  readily  prove. 

The  Princess  was  burned  at  a  court-ball,  on  the  night  of  Sunday, 
July  1,  1810,  and  under  circumstances  which  made  her  name  famous 
as  a  self-sacrificing  heroine.  This  fact  has  made  it  a  comparatively 
easy  matter  to  secure  the  whole  of  the  truth  required.  The  Gazette 
Rationale  ou  Moniteur  Universal,  the  official  journal  of  the  empire, 
of  Tuesday,  July  3,  1810,  gives  the  facts  of  her  death,  and  states 
that  at  dav-break,  on  July  2,  a  disfigured  body  was  discovered  in 
the  debris  of  the  hall,  which  Dr.  Gall  believed  to  be  that  of  the 
Princess,  about  which  there  was  no  doubt,  when  an  ornament  known 
to  have  been  worn  by  her,  was  found  upon  the  neck.  This  paper 
also  states,  that  "the  ]?rincess  was  the  mother  of  eight  children,"  and 

ri  See  article  Iby  Ed.  in  Am.  Jour,  of  Med.  Sci.,  Oct.  1879,  p.  389.] 


CiBSAREAN    SECTION.  513 

tliat  slic  was  '■'•four  monilis  prefjnant.''''     The  Journal  dc  I'Empirc,  of 
July  4,  gives  virtually  tlie  same  account. 

Besides  this  wo  have  statements^  to  the  effect  that  her  bod}^  was 
almost  entirely  burned  to  a  crisp  mass,  so  that  an  operation  was  an 
impossibility.  In  the  Journal  de  Medicine,  by  Drs.  Corvisart,  Leroux, 
and  Boyer,  there  is  no  reference  to  the  case  in  the  monthly  numbers 
from  July,  1810,  to  Jan.  1811.  I  hope,  therefore,  as  I  have  proved 
that  the  women  was  only  pregnant  four  months,  and  that  her  body 
was  burned  beyond  the  possibility  of  an  operation,  that  no  future 
obstetrical  writer  will  record  the  case,  as  "  perhaps  the  best  aTithenti- 
cated"  of  all  this  class  of  historical  marvels,  or  express  any  doubt 
about  it ;  let  the  record  be  dead  and  buried  historically. — Ed.] 

Since,  then,  there  is  a  chance,  however  slight,  of  saving  the  child's 
life,  we  are  bound  to  perform  the  operation,  even  when  so  much  time 
has  elapsed  as  to  render  the  chances  of  success  extremely  small.  It 
might  be  considered  almost  superfluous  to  insist  ou  the  necessity  of 
assuring  ourselves  of  the  mother's  death  before  commencing  the  neces- 
sary incisions ;  but,  unfortimately,  numerous  instances  are  known  in 
which  mistakes  in  diagnosis  have  been  made,  and  in  Avhicli  the  first 
steps  of  the  operation  have  shown  that  the  mother  was  still  alive. 
The  operation  should,  therefore,  always  be  performed  with  the  same 
care  and  caution  as  if  the  mother  were  living.  If  death  have 
occurred  during  labor,  some  have  advised  version  as  a  preferable 
alternative.  This  can  only  be  resorted  to,  with  any  hope  of  success, 
if  the  passages  be  in  a  condition  to  admit  of  delivery  with  rapiditj?- ; 
otherwise  the  delay  required  for  dilatation,  even  when  forcibly 
accomplished,  and  the  drawing  of  the  child  through  the  pelvis,  will 
be  almost  necessarily  fatal.  The  only  argument  in  favor  of  version 
is,  that  it  is  less  painful  to  the  friends ;  and,  if  they  manifest  a  decided 
objection  to  the  Oaesarean  section,  there  can  be  no  reason  why  an 
attempt  to  save  the  child  in  this  way  should  not  be  made. 

Causes  of  Death  after  Csesarean  Section. — The  causes  of  death  after 
the  Csesarean  section  may,  speaking  generally,  be  classed  under  four 
principal  heads ;  hemorrhage,  peritonitis  and  metritis,  shock,  septi- 
caemia, and  exhaustion  from  long  delay.  These  are  pretty  much  the 
same  as  those  following  ovariotomy  and  the  resemblance  between 
the  two  operations  is  so  great  that  modern  experience  as  to  the  best 
mode  of  performing  ovariotomy,  as  well  as  regards  the  after  treat- 
ment, may  be  taken  as  a  guide  in  the  management  of  cases  of  Csesar- 
ean section. 

Hemorrhage  is  Frequent.^  although  Seldovi  Fatal. — Hemorrhage  to 
an  alarming  extent  is  a  frequent  complication,  although  seldom  the 
cause  of  death.  Thus  out  of  88  operations,  the  particulars  of  which 
have  been  carefully  noted,  severe  hemorrhage  occurred  in  1-1,  6  of 
which  terminated  successfully,  and  in  4  onlj^  could  the  fatal  result  be 
ascribed  to  the  loss  of  blood.  In  1  of  these  the  source  of  the  hemor- 
rhage is  not  mentioned ;  in  another  it  came  from  the  wound  in  the 

['  Alison's  "History  of  Europe,"  Mad.  Junot's  "Memoirs  of  Napoleon,  his  Court 
and  Family."] 


514  OBSTETRIC  OPERATIONS. 

abdominal  wall,  and  in  tlie  otlier  2  from  tlie  uterine  incision  being 
made  directly  over  tlie  placenta.  In  neither  of  the  2  latter  was  the 
loss  of  blood  immediately  fatal ;  for  it  was  checked  by  uterine  con- 
traction, and  only  recurred  after  many  hours  had  elapsed.  The 
divided  uterine  sinuses,  and  the  open  mouths  of  the  vessels  at  the 
placental  site,  are  the  most  common  sources  of  hemorrhage. 

Means  of  avoidiny  the  Rish. — Much  may  be  done  to  diminish  the 
risk  of  bleeding,  but  even  with  every  precaution,  it  must  be  a  source 
of  danger.  Hemorrhage  from  the  abdominal  wall  may  be  best 
prevented  by  making  the  incision  as  nearly  as  possible  in  the  line 
of  the  linea  alba,  so  as  not  to  wound  the  epigastric  arteries,  and  by 
tying  any  bleeding  vessels  as  we  proceed.  The  principal  loss  of 
blood  will  be  met  with  in  dividing  the  uterus  ;  and  this  will  be 
greatest  when  the  incision  is  near  or  over  the  placental  site,  where 
the  largest  vessels  are  met  with.  We  are  recommended  to  ascertain 
the  position  of  the  placenta  by  auscultation,  and  thus,  if  possible,  to 
avoid  opening  the  uterus  near  its  insertion.  But  even  if  we  admit 
the  placental  souffle  to  be  a  guide  to  its  situation,  if  the  placenta  be 
attached  to  the  anterior  walls  of  the  uterus,  a  knowledge  of  its  posi- 
tion Avould  not  always  enable  us  to  avoid  opening  the  uterus  in  its 
immediate  vicinity.  We  must,  in  the  event  of  its  lying  under  the 
incision,  rather  hope  to  control  the  hemorrhage  by  removing  it  at 
once  from  its  attachments,  and  rapidly  emptying  the  uterus.  When 
the  child  has  been  removed  there  may  be  a  large  escape  of  blood ; 
but  this  will  generally  be  stopped  by  the  contraction  of  the  uterus, 
in  the  same  manner  as  after  natural  labor.  Should  contraction  not 
take  place,  the  uterus  may  be  firmly  grasped  for  the  purpose  of 
exciting  it.  This  plan  is  advocated  by  Winckel,  who  had  a  large 
experience  in  the  operation ;  and  by  using  free  compression  in  this 
way,  and  making  a  point  of  not  closing  the  wound  until  the  uterus 
is  firmly  contracted,  he  has  never  met  with  any  inconvenience  from 
hemorrhage.  If  bleeding  continue,  styptic  applications  may  be  used, 
as  in  a  case  reported  by  Hicks,  who  was  obliged  to  swab  out  the 
uterine  cavity  with  a  solution  of  perchloride  of  iron. 

Peritonitis  and  Metritis  are  frequent  Causes  of  Death. — Among  tbe 
most  frequent  causes  of  death  are  peritonitis  and  metritis.  Kaj^ser 
attributes  the  fatal  result  to  them  in  77  out  of  123  unsuccessful  cases. 

The  mere  division  of  the  peritoneum  will  not  account  for  the  fre- 
quency of  this  complication,  since  its  occurrence  is  considerably  more 
frequent  than  after  ovariotomy,  in  which  the  injury  to  the  peritoneum 
is  quite  as  great,  and  indeed  greater,  if  we  take  into  account  the 
adhesions  which  have  to  be  divided  or  torn  in  that  operation. 

The  division  of  the  uterus  must  be  regarded  as  one  source  of  this 
danger.  Dr.  West  lays  great  stress  on  its  unfavorable  condition 
after  delivery  for  reparative  action.  He  believes  that  the  process  of 
involution  or  fatty  degeneration  which  commences  in  the  muscular 
fibres  previous  to  delivery,  renders  them  peculiarly  unfitted  to  cica- 
trize ;  and  he  points  out  that,  on  post-mortem  examination,  the  edges 
of  the  incision  have  been  found  dry,  of  unhealthy  color,  gaping,  and 
showing  no  tendency  to  heal.     On  this  account  Hicks  and  others 


CiESAllEAN    SECTION.  515 

have  operated  ten  days  or  more  before  the  fall  period  of  labor,  in 
the  hope  that  the  risk  from  this  source  might  be  avoided.  It  is  by 
no  means  certain,  however,  that  the  change  in  the  uterine  fibres  is 
the  cause  of  the  wound  not  healing,  and  involution  will  commence 
at  once  when  the  uterus  is  emptied,  even  if  the  full  period  of  preg- 
nancy have  not  arrived.  As  a  point  of  ethics,  moreover,  it  is  question- 
able if  we  are  justified  in  anticipating  the  date  of  so  dangerous  an 
operation,  even  by  a  few  weeks,  unless  the  benefit  to  be  derived  is 
very  decided  indeed. 

Escape  of  Lochia  and  other  Fluids  into  the  Peritoneal  Cavity. — One 
important  cause  of  peritonitis  is  the  escape  of  the  lochia  through  the 
uterine  incision  into  the  cavity  of  the  peritoneum,  which  there  de- 
compose and  act  as  an  unfailing  source  of  irritation.  This  may  be 
prevented,  to  a  great  extent,  by  seeing  that  the  os  uteri  is  patulous, 
so  as  to  afford  a  channel  for  the  escape  of  discharges,  and  by  closing 
the  uterine  wound  by  sutures.  In  addition  there  is  the  danger 
arising  from  blood  ancl  liquor  amnii  escaping  into  the  peritoneum, 
and  subsequently  decomposing.  There  is  little  evidence  that  "  la 
toilette  du  peritoine,"  on  Avhich  ovariotomists  now  lay  so  much 
stress,  has  ever  been  particularly  atttended  to  in  Gsesarean  operations. 

The  Unhealthy  Gondition  of  the  Patient  is  the  Chief  Source  of  Danger . 
— The  chief  predisposing  cause  of  these  inflammations,  however,  must 
be  looked  for  in  the  condition  of  the  patient,  just  as  asthenic  inflam- 
mation in  ovariotomy  is  most  frequently  met  with  in  those  whose 
general  health  is  broken  down  by  the  long  continuance  of  the  disease. 
We  are  fully  justified,  therefore,  in  assuming  that  peritonitis  and 
metritis  will  be  more  likely  to  occur  after  the  Coesarean  section  when 
that  operation  has  been  unnecessarily  delayed,  and  when  the  patient 
is  exhausted  by  a  protracted  labor.  In  proof  of  this  we  find  that,  in 
the  large  proportion  of  the  cases  above  mentioned,  peritonitis  oc- 
curred when  the  operation  was  performed  under  unfavorable  con- 
ditions. 

Septicsemia. — The  sources  of  septicsemia  are  abundantly  evident, 
not  the  least,  probably,  being  absorption  by  the  open  vessels  in  the 
uterine  incision. 

Nervous  Shock. — 'The  last  great  danger  is  general  shock  to  the  ner- 
vous system.  In  Kayser's  123  cases,  30  of  the  deaths  are  referred 
to  this  cause.  In  the  large  majority  of  these  the  patient  was  pro- 
foundly exhausted  before  the  operation  was  begun.  It  is  in  predis- 
posing to  these  nervous  complications,  that  we  should,  a  priori,  expect 
that  vaccination  and  delay  would  be  most  hurtful ;  and  in  operating 
when  the  patient's  strength  is  still  unimpaired,  we  afford  her  the  best 
chance  of  bearing  the  inevitable  shock  of  an  operation  of  such  mag- 
nitude. 

Secondary  Dangers. — In  addition  a  few  cases  have  been  lost  from 
accidental  complications,  which  are  liable  to  occur  after  any  serious 
operation,  and  which  do  not  necessarily  depend  on  the  nature  of  the 
procedure. 

Danger  to  Child  from  Portions  of  its  Body  heing  caught  hy  the  Con- 
tracting Uterus. — There  is  only  one  source  of  danger,  special  to  the 


516  OBSTETRIC  OPERATIONS. 

cliild,  which  is  worthy  of  attention.  As  the  infant  is  being  removed 
from  the  cavity  of  the  uterus,  the  muscular  parietes  sometimes  con- 
tract with  great  rapidity  and  force,  so  as  to  seize  and  retain  some 
part  of  its  body.  This  occurred  in  2  of  Dr.  Radford's  cases,  and  in  1 
of  them  it  is  stated  that  "  the  child  was  vigorously  alive  Avhen  first 
taken  hold  of,  but,  from  the  length  of  time  occupied  in  extracting  the 
head,  it  became  so  enfeebled  as  to  show  only  slight  signs  of  life,"  and 
subsequently  all  attempts  at  resuscitation  failed.  I  have  myself  seen 
the  head  caught  in  this  way,  and  so  forcibly  retained  that  a  second  in- 
cision was  required  to  release  it.  In  Dr.  Radford's  cases  the  placenta 
happened  to  be  immediately  under  the  incision,  and  he  attributes  the 
inordinate  and  rapid  contraction  of  the  uterus  to  its  premature  sepa- 
ration. It  is  difficult  to  believe  that  this  was  more  than  a  coinci- 
dence, because  the  contraction  does  not  take  place  until  the  greater 
part  of  the  child's  body  has  been  withdrawn,  and  because  numerous 
cases  are  recorded  in  which  the  uterus  was  opened  directly  over  the 
placenta,  or  in  which  it  was  lying  loose  and  detached,  in  none  of 
which  this  accident  occurred.  The  true  explanation  may,  I  think, 
be  found  in  the  varying  irritability  of  the  uterus  in  different  cases. 

Irrespective  of  the  risk  of  portions  of  the  child  being  caught  and 
detained,  rapid  contraction  is  a  distinct  advantage,  since  the  danger 
of  hemorrhage  is  thereby  much  diminished.  Serious  consequences 
may  be  best  avoided  by  removing,  when  practicable,  the  head  and 
shoulders  of  the  child  first,  or  by  employing  both  hands  in  extrac- 
tion, one  being  placed  near  the  head,  the  other  seizing  the  feet. 
Either  of  these  methods  is  preferable  to  the  common  practice  of  lay 
ing  hold  of  the  part  that  may  chance  to  lie  most  conveniently  near 
the  line  of  incision.  If  this  point  were  properly  attended  to,  al- 
though the  detention  of  the  lower  extremities  might  occasionally 
occur,  the  life  of  the  child  would  not  be  imperilled. 

The  po'eparation  of  the  j'^atient  for  the  operation  should  seriously  oc- 
cupy the  attention  of  the  practitioner,  and  this  is  the  more  essential, 
since  almost  all  patients  requiring  the  Osesarean  section  are  in  a 
wretchedly  debilitated  condition.  If  the  patient  be  not  seen  until 
she  is  actually  in  labor,  of  course  this  is  out  of  the  question.  But 
this  will  rarely  be  the  case,  since  the  deformed  condition  of  the 
patient  must  generally  have  attracted  attention.  Eveiy  possible 
means  should  be  taken,  therefore,  when  practicable,  to  improve  the 
general  health  by  abundance  of  simple  and  nourishing  diet,  plenty 
of  fresh  air,  and  suitable  tonics  (amongst  which  preparations  of  iron 
should  occupv  a  prominent  place),  while  the  state  of  the  secretions, 
the  bowels,  skin,  and  kidneys,  should  be  specially  attended  to. 
Whenever  it  is  possible  a  large,  airy  apartment  should  be  selected 
for  the  operation,  which  should  never  be  done  in  a  hospital,  if  other 
arrangements  be  practicable.  These  details  may  seem  trivial  and 
unnecessary ;  but  to  insure  success  in  so  hazardous  an  under- 
taking, no  care  can  be  considered  superfluous,  and  probably  the 
want  of  attention  to  such  points  has  had  much  to  do  with  increasing 
the  mortality. 

[In  the  United  States,  where  osteo-malacia  has  on  no  one  occasion 


CiESAllEAN    SECTION.  517 

been  the  cause  of  dcfonnity  requiring  the  operation  of  section,  the 
patients  are  generally  m  a  fliir  condition  of  health,  although  not 
usually  either  strong  or  plethoric.  So  far  from  there  being  an  op- 
portunity to  put  them  under  preparatory  treatment,  the  trouble  is, 
that  the  operator  seldom  sees  them  until  entirely  too  late.  In  the 
class  of  patients  to  be  operated  upon  here,  there  is  rarely  sought,  until 
frightened  into  the  necessity  of  doing  it,  either  an  accoucheur  or  sur- 
geon of  the  requisite  skill  and  experience. — Ed.] 

Question  of  Ti'me  to  he  Selected  for  the  Operaiion. — The  question 
arises  whether  we  should  operate  before  labor  has  commenced.  By 
selecting  our  own  time,  as  some  have  advised,  we  certainly  have  the 
advantage  of  operating  under  the  most  favorable  conditions,  instead 
of  possibly  hurriedly.  There  are,  however,  numerous  advantages  in 
waiting  until  spontaneous  uterine  action  has  commenced,  which 
seem  to  me  to  more  than  counterbalance  the  advantages  of  choosing 
our  own  time.  Prominent  among  these  is  the  partial  opening  of  the 
OS  uteri,  so  as  to  afford,  a  channel  for  the  escape  of  the  lochia,  and 
the  certainty  of  active  contraction  of  the  uterus,  to  arrest  hemor- 
rhage. Barnes  recommends  that  premature  labor  should  be  first 
induced,  and  then  the  operation  performed.  This  seems  to  me  to 
introduce  a  needless  element  of  complexity  ;  and  besides,  in  cases  of 
great  deformity,  it  is  by  no  means  always  cas}^  to  reach  the  cervix 
with  the  view  of  bringing  on  labor.  All  needful  arrangements 
should  be  made,  so  as  to  avoid  hurry  and  excitement  when  the 
operation  is  commenced,  and  we  may  then  wait  patiently  until  labor 
has  fairly  set  in. 

The  Administration  of  Anaesthetics. — -The  operation  itself  is  simple. 
The  patient  should  be  placed  on  a  table,  in  a  good  light,  and  with 
the  temperature  of  the  room  raised  to  about  Q)b^.  Chloroform  has 
so  frequently  been  followed  by  severe  vomiting,  that  it  is  probably 
better  not  to  administer  it.  For  the  same  reason  Mr.  Spencer  AY  ells 
has  long  given  up  using  it  in  ovariotomj^,  and  finds  that  chloro- 
methyl  answers  admirably;  ether  also  is  devoid  of  the  disadvantages 
of  chloroform.  In  one  or  two  cases  local  aneesthesia  has  been  used, 
by  means  of  two  spray  producers  acting  simultaneously  ;  and  this 
plan,  if  the  patient  have  suf&cient  fortitude  to  dispense  with  general 
anesthesia,  has  the  further  advantage  of  stimulating  the  uterus  to 
powerful  contraction. 

Description  of  the  Opercition. — The  incision  should  be  made  as  much 
as  possible  in  the  line  of  the  linea  alba,  so  as  to  avoid  wounding  the 
epigastric  arteries.  On  account  of  the  deformity,  the  configuration 
of  the  abdomen  is  often  much  altered,  and  some  have  advised  that 
the  incision  should  be  made  oblique  or  transverse,  and  on  the  most 
prominent  part  of  the  abdomen.  The  risk  of  hemorrhage  being  thus 
much  increased,  the  practice  is  not  to  be  recommended.  The  incision, 
commencing  a  little  above  the  umbilicus,  is  carried  down  for  about 
three  inches  below  it.  The  skin  and  muscular  fibres  are  carefully 
divided,  layer  by  layer,  until  the  shining  surface  of  the  peritoneum 
is  reached,  and  any  bleeding  vessels  should  be  secured  as  we  proceed. 
A  small  opening  is  now  made  in  the  peritoneum,  which  should  be 


518  OBSTETRIC  OPERATIONS. 

laid  open  along  tlie  whole  length  of  the  incision,  upon  two  fingers  of 
the  left  hand  introduced  as  a  guide.  Before  incising  the  uterus  an 
assistant  should  carefully  support  it  in  a  proper  position,  and  push 
it  forward  by  the  hands  placed  on  either  side  of  the  incision,  so  as  to 
bring  its  surface  into  apposition  with  the  external  wound,  and  pre- 
vent the  escape  of  the  intestines.  If  we  have  reason  to  believe  that 
the  placenta  is  situated  anteriorly,  we  may  incise  the  uterus  on  one 
or  other  side ;  otherwise  the  line  of  incision  should  be  as  nearly  as 
possible  central.  The  substance  of  the  uterus  is  next  divided  until 
the  membranes  are  reached,  which  are  punctured,  and  divided  in  the 
same  way  as  the  pei'itoneum.  The  uterine  incision  should  be  of  the 
same  length  as  that  in  the  abdomen,  and  it  should  not  be  made  too 
near  the  fundus  ;  for  not  only  is  that  part  more  vascular  than  the 
body  of  the  uterus,  but  wounds  in  that  situation  are  more  apt  to 
gape,  and  do  not  cicatrize  so  favorably.  After  the  uterus  is  opened, 
Dr.  "Winckel  recommends  that  the  fingers  of  an  assistant  should  be 
placed  in  the  two  terminal  angles  of  the  wound,  so  that  the  ends  of 
the  incision  may  be  hooked  up,  and  brought  into  close  apposition 
with  the  abdominal  opening.  By  this  means  he  prevents  not  only 
the  escape  of  blood  and  liquor  amnii  into  the  cavity  of  the  perito- 
neum, but  also  the  protrusion  of  the  abdominal  viscera. 

Removal  of  the  Child. — The  child  should  now  be  carefully  removed, 
the  head  and  shoulders  being  taken  out  (if  possible)  at  first ;  the 
placenta  and  membranes  are  afterwards  extracted.  Should  the  pla- 
centa be  unfortunately  found  immediately  under  the  incision,  a  con- 
siderable loss  of  blood  is  likely  to  take  place,  which  can  only  be 
checked  by  removing  it  from  its  attachments,  and  concluding  the 
operation  as  rapidly  as  possible. 

hrii^ortcmce  of  securing  Uterine  Contraction. — As  soon  as  the  child 
and  the  secundines  have  been  extracted,  the  sooner  the  uterus  con- 
tracts the  better.  It  will  usually  do  so  of  itself,  but  should  it  remain 
lax  and  flabby,  it  should  be  pressed  and  stimulated  by  the  hand. 
We  are  specially  warned  against  handling  the  uterus  by  Eamsbo- 
thani  and  others  ;  but  there  seems  no  valid  reason  why  we  should  not 
restrain  hemorrhage  in  this  way,  as  after  a  natural  labor.  The  in- 
tervention of  the  abdominal  parietes,  in  their  lax  condition  after 
delivery,  can  make  very  little  difference  between  the  two  cases.  Er- 
gotine  administered  hypodermicallj^,  will  also  be  useful  in  promoting 
efficient  contraction. 

Closure  of  the  Uterine  and  Ahdominal  ^¥ounds. — The  advisability 
of  closing  the  uterine  wound  by  sutures  is  a  mooted  point.  The 
balance  of  evidence  is  certainly  in  favor  of  this  practice,  as  tending 
to  prevent  the  escape  of  the  lochia  into  the  peritoneal  cavity.^     Inter- 

['  Sutures,  chiefly  of  silver  wire  have  been  used  in  17  operations  out  of  112  in  the 
United  States.  The  catgut  suture,  whether  plain  or  carholized,  cannot  be  too  strongly 
condemned,  as  it  has  signally  failed  on  the  continent,  and  has  been  decided  to  be 
unreliable  by  the  Obstetrical  Society  of  London,  for  it  does  not  hold  even  when  treble- 
knotted.  It  has  only  been  used  once  in  the  United  States,  and  the  wound  gaped  ojjen. 
Tho  material  stretches  as  well  as  becomes  untied.  The  fishing-gut  suture  has  taken 
its  place  abroad,  as  it  does  not  elongate,  and  is  not  rapidly  dissolved.  The  wire- 
suture  has  saved  life  in  some  cases  of  complete  uterine  atony  in  our  country. — Ei;.] 


CESAREAN    SECTION.  519 

rupted  sutures  of  silver  wire  or  carbolized  gut  may  be  used,  and  cut 
short ;  or,  as  successfully  practised  by  Spencer  Wells,  a  continuous 
silk  suture  may  be  applied,  one  end  being  passed  through  the  os  into 
the  vagina,  by  which  it  is  subsequently  withdrawn.  Before  closing 
the  uterine  wound  one  or  two  fingers  should  be  passed  through  the 
cervix,  to  insure  its  being  patulous.  A  free  escape  of  the  lociiia  in 
this  direction  is  of  great  consequence,  and  Winckel  even  advises  the 
placing  of  a  strip  of  lint,  soaked  in  oil,  in  the  os  so  as  to  keep  up  a 
free  exit  for  the  discharge. 

A  point  of  great  importance,  and  not  sufficiently  insisted  on,  is  the 
advisability  of  not  closing  the  abdominal  wound  until  we  are  thor- 
oughly satisfied  that  hemorrhage  is  completely  stopped,  since  any 
escape  of  blood  into  the  peritoneum  would  very  materially  lessen 
the  chances  of  recovery.  In  a  successful  case  reported  by  Dr.  New- 
man,^ the  wound  was  not  closed  for  nearly  an  hour.  Before  doing 
so  all  blood  and  discharges  should  be  carefully  removed  from  the 
peritoneal  cavity,  by  clean  soft  sponges  dipped  in  warm  water.  The 
abdominal  wound  should  be  closed  from  above  downwards,  by  hare- 
lip pins,  wire  or  silk  sutures,  which  should  be  inserted  at  a  distance 
of  an  inch  from  each  other,  and  passed  entirel}^  through  the  abdomi- 
nal walls  and  the  peritoneum,  at  some  little  distance  from  the  edges 
of  the  incision,  so  as  to  bring  the  two  surfaces  of  the  peritoneum  into 
contact.  By  this  means  we  insure  the  closure  of  the  peritoneal 
cavity,  the  opposed  surfaces  adhering  with  great  rapidity.  The  sur- 
face of  the  wound  is  then  covered  with  pads  of  folded  lint,  kept  in 
position  by  long  strips  of  adhesive  plaster,  and  the  whole  covered 
with  a  soft  flannel  belt. 

Subsequent  Management. — Into  the  subsequent  treatment  it  is  un- 
necessary to  enter  at  any  length,  since  it  must  be  regulated  by  general 
principles,  each  symptom  being  met  as  it  arises.  It  has  been  cus- 
tomary to  administer  opiates  freely  after  the  operation ;  but  they 
seem  to  have  a  tendency  to  produce  sickness  and  vomiting,  and  ought 
not  to  be  exhibited  unless  pain  or  peritonitis  indicate  that  they  are 
required.  In  fact,  the  treatment  should  in  no  way  differ  from  that 
usual  after  ovariotomy,  and  the  principles  that  should  guide  us  will 
be  best  shown  by  the  following  quotation  from  Mr.  Spencer  Wells's 
description  of  that  operation  :  "  The  principles  of  after-treatment  are 
—to  obtain  extreme  quiet,  comfortable  warmth,  and  perfectly  clean 
linen  to  the  patient ;  to  relieve  pain  by  warm  applications  to  the 
abdomen,'' and  by  opiate  enemas;  to  give  stimulants  when  they  are 
called  for  by  failing  pulse  or  other  signs  of  exhaustion;  to  relieve 
sickness  by  ice,  or  iced  drinks ;  and  to  allow  plain,  simple,  but  nour- 
ishing food.  The  catheter  must  be  used  every  six  or  eight  hours, 
until  the  patient  can  move  without  pain.  The  sutures  are  removed 
on  the  third  day,  unless  tympanitic  distension  of  the  stomach  or  in- 
testines endanger  re-opening  of  the  wound.  In  such  circumstances 
they  may  be  left  for  some  days  longer.  The  superficial  sutures  may 
remain  until  union  seems  quite  firm." 

'  Obst.  Trans.,  vol.  viii. 


520  OBSTETRIC  OPERATIONS. 

Forro\s  Operation. — Porro  of  Pavia  has  recentlj  suggested  and  car- 
ried into  practice  a  modification  of  the  Ciesarean  section,  which  con- 
sists in  the  removal  of  the  uterus  and  ovaries,  after  the  extraction  of 
the  child.  The  advantages  are  the  removal  of  the  wounded  organ 
from  the  abdominal  cavity,  thus  lessening  the  chances  of  septicaemia 
and  hasmorrhage,  and  leaving  a  smaller  traumatic  surface,  which  is 
fixed  externally  in  the  abdominal  incision.  The  operation  has  now 
been  performed  25  times,  with  10  recoveries  and  15  deaths.  Although 
it  is  not  easy,  in  an  operation  so  recently  introduced,  to  give  a  very 
positive  opinion  as  to  its  merits,  it  obviously  offers  some  advantages 
worthy  of  careful  consideration.  The  fact  that  it  renders  future 
pregnancies  impossible,  need  certainly  not  act  as  argument  against 
its  adoption,  considering  the  class  of  cases  in  which  the  Cassarean 
section  is  required.  The  operation  itself  is  simple.  As  performed 
by  Spaeth  the  hemorrhage  was  controlled  by  the  chain  of  an  ecra- 
seur  thrown  round  the  uterus,  which  was  then  cut  off,  along  with 
the  ovaries,  and  attached  to  the  abdominal  wound,  as  in  ovariotomy. 
Four  drainage  tubes  were  inserted,  two  in  Douglas's  space,  and  two 
higher  up  on  either  side.  The  whole  operation  was  performed  anti- 
septically  and  offered  no  difficulties.^ 

[As  the  author's  record  is  not  complete,  I  will  state  that  up  to  this 
time  as  far  as  ascertainable,  the  operation  has  been  performed  32 
times,  with  15  recoveries ;  viz..  United  States  1,  Italy  12,  Austria  9, 
Germany  2,  France  3,  Belgium  2,  Denmark  1,  Switzerland  1,  and 
Eussia  1, 

This  operation  of  removing  the  uterus  and  ovaries  as  supplemental 
to  the  Ciesarean  section,  is  of  English  origin,  and  was  first  recom- 
mended as  an  improvement  upon  the  old  method  because  believed  to 
be  less  dangerous,  by  Dr,  James  Blundell  of  London,  in  his  Guy's 
Hospital  Lectures  in  1828,^  After  a  series  of  experiments  in  abdom- 
inal surgery  upon  the  lower  animals,  Prof,  Blundell  became  con- 
vinced that  this  method  of  operating  should  be  adopted  with  reference 
to  the  human  female,  and  urged  it  upon  his  class  as  well  worthy  of 
trial  and  adoption. 

The  first  actual  operation  of  removing  the  uterus  of  a  tvoman  in  lahor 
was  performed  in  Boston,  July  21st,  1869,  by  Prof.  Horatio  E.  Storer,^ 
for  the  arrest  of  an  uncontrollable  hemorrhage  following  the  Csesarean 
section,  in  a  case  where  pregnancy  was  complicated  with  fibro-cystic 
disease,  the  sides  of  the  uterine  incision  being  two  inches  thick  :  the 
woman  lived  68  hours. 

The  operation  of  Edoardo  Porro  was  performed  with  success  on 
May  21st,  1876 :  and  was  succeeded  with  the  same  result  by  Prof 
Spath,  at  the  Lying-in  Hospital  of  Vienna,  twelve  days  later.  This 
gave  an  impetus  to  the  expedient  as  a  hospital  improvement,  and 
now  the  method  has  been  tried  on  more  than  a  score  of  hospital  cases 
on  the  Continent,  in  a  number  of  localities.     The  fact  that  four  ope- 

• 

1  Weiner  Med.  Woclienschrift,  1878. 

[2  Lancet,  vol,  ii.,  p.  167,  London,  1828,] 

[3  Jour.  GyuecoL  Soo.  Boston,  Oct.  1869,  page  223.] 


CiESAREAN    SECTION.  621 

rations  have  succeeded  out  of  seven,  in  the  Vienna  Hospital,  where 
all  the  Caasarean  cases  had  proved  fatal  for  a  century,  under  the  old 
method  ;  and  that  Prof.  Tarnier  succeeded  also  at  the  Maternite  of 
Paris,  where  there  had  been  nothing  but  failures  since  1787,1^3 
made  a  very  decided  impression  on  the  minds  of  the  leading  Euro- 
pean professors  of  Obstetrics. 

Tlie  Iluller  MeLliod. — This  consists  in  the  elevation  of  the  gravid 
uterus  from  the  abdominal  cavity  by  the  long  incision ;  then  con- 
stricting the  cervix  to  prevent  all  hemorrhage  ;  then  evacuating  the 
uterus  so  as  to  prevent  all  entrance  of  fluid  into  the  abdomen,  and 
finally  cutting  through  the  cervix.  This  was  devised  by  Prof.  Miiller, 
of  Berne,  Switzerland,  and  has  been  performed  several  times  with  a 
fair  prospect  of  success.     The  fostus  is  readily  resuscitated. 

Prof.  Litzman,  of  Kiel,  Denmark,  tried  the  apparatus  of  his  col- 
league Esmark  in  one  case  which  he  lost ;  and  then  in  a  short  time  the 
plan  of  Miiller,  but  the  woman  died  of  peritonitis  on  the  sixteenth  day. 

Prof.  Wasseige,  of  Liege,  proposes  to  use  a  ribbon,  instead  of  a  wire 
constrictor,  as  in  one  of  his  cases  the  wire  opened  an  artery  in  the 
cervix.  The  chaiu-dcraseur,  serre-uo3ud  of  Cintrat,  wire  dcraseur, 
and  clamp,  have  all  had  their  advocates. 

As  we  have  had  but  4  hospital  Ciesarean  operations  in  112  cases 
in  the  United  States,  there  is  no  demand  for  the  Porro  method  as  a 
hospital  improvement  with  us.  AVe  have  had  cases  in  which  I 
believe  the  plan  might  be  of  value ;  such  as  those  with  uterine 
fibroids,  and  some  similar  to  the  second  case  of  Prof.  Tarnier,  i.  e., 
women  long  in  labor,  and  with  a  putrid  foetus  in  utero.  His  patient 
was  four  feet  high,  and  the  waters  had  been  broken  three  days. 
Such  patients  have  occasionally  lived  with  us,  but  the  great  majority 
have  died.  If  all  our  Cassarean  operations  were  early,  there  would 
be  but  a  very  limited  use  for  the  Porro  method  here.  "Where  there 
is  a  uterine  tumor  and  a  prospective  danger  of  hemorrhage,  I  believe 
that  Miiller's  method  would  ofi'er  the  best  hope  of  success  — Ed.] 

Suhstitute  for  the  Cesarean  Section  ;  Sym.physeotoirty. — Bearing  in 
mind  the  great  mortality  attending  the  Cesarean  section,  it  is  not 
surprising  that  obstetricians  should  have  anxiously  considered  the 
possibility  of  devising  a  substitute,  which  should  afford  the  mother 
a  better  chance  of  recovery.  The  first  proposal  of  the  kind  was  one 
from  which  great  results  were  at  first  anticipated.  In  1768  Sigault, 
then  a  student  of  medicine  in  Paris,  suggested  sym.ph.yseotomy^  which 
consists  in  the  division  of  the  symphysis  pubis,  with  a  view  of  allow- 
ing the  pubic  bones  to  separate  sufficiently  to  admit  of  the  passage 
of  the  child.  Although  at  first  strongly  opposed,  it  was  subsequently 
ardently  advocated  by  many  obstetricians,  and  was  often  performed 
on  the  Continent,  and  in  a  few  cases  in  this  country. 

The  Operation  is  Admitted  to  he  Useless. — It  is  generally  admitted 
that  it  is  quite  impossible  to  make  this  a  substitute  for  the  Csesarean 
section,  since  the  utmost  gain  which  even  a  wide  separation  of  the 
symphysis  pubis  would  give  would  be  altogether  insufficient  to  admit 
of  the  passage  of  even  a  mutilated  foetus.  Dr.  Churchill  concludes 
that,  even  if  it  were  possible  to  separate  it  to  the  extent  of  four 
34 


622       "  OBSTETRIC  OPERATIONS. 

inches,  we  should  only  have  an  increase  of  from  four  lines  to  half  an 
inch  in  the  antero-posterior  diameter,  in  which  the  obstruction  is 
generally  most  marked.  In  the  lesser  degrees  of  deformity  this  might 
possibly  be  sufficient  to  allow  the  foetus  to  pass  ;  but  the  risk  of  the 
operation  itself,  and  the  subsequent  ill  effects,  altogether  contra-indi- 
cate  it  in  cases  of  this  description. 

\_The  Csesarean  Operation  in  America. — The  changes  in  my  record 
since  the  publication  of  the  last  edition  of  this  work  have  necessi- 
tated the  remodelling  of  this  entire  article.  Ten  years  of  research 
have  satisfied  me  that  few  Europeans  yet  understand  our  exact  posi- 
tion with  reference  to  this  critical  operation,  made,  however,  far 
more  dangerous  than  it  ought  to  be,  by  an  almost  criminal  delay  in 
operating. 

Statistics  have  often  been  very  much  decried,  and  deservedly  so, 
because  they  do  not  in  general  represent  the  whole  truth.  Few  men 
have  the  patience  to  hunt  up  the  unpublished  records  of  anything, 
much  less  of  a  rarely  performed  operation,  in  a  country  as  vast  as 
this.  And  then  when  we  do  hunt  them  out,  the  cases,  as  a  whole, 
do  not  properly  represent  the  mortality  and  dangers  of  the  operation. 
We  must  sift  and  condemn  until  we  separate  the  bad  surgery  from 
the  good,  and  the  properly  conducted  from  the  improperly  managed 
cases.  We  average  the  whole  collection  to  learn  what  the  ratio  of 
deaths  has  been;  and  we  do  the  same  with  the  properly  managed 
cases,  to  find  out  what  it  might  and  should  have  been.  Acting  on 
this,  I  present  119  American  Caesarean  cases,  with  54  women  saved. 
Of  these,  112  belong  to  the  United  States,  out  of  which  48  women 
recovered ;  52  children  were  delivered  alive,  of  whom  9  soon  perished, 
leaving  43  saved. 

The  published  cases,  such  as  statistical  records  are  usually  made 
"up  from,  number  64,  of  which  35  women  recovered,  or  an  average 
of  59j-\  per  cent.  The  unpublished  cases,  some  of  them  older  than 
any  of  the  published,  number  48,  of  which  13  were  saved,  or  an 
average  of  27  per  cent.,  making  the  average  in  the  112,  42f  per 
cent,  of  women  saved. 

Dr.  Playfair  remarks  on  page  507,  "Until  we  are  in  possession  of 
a  sufficient  number  of  cases  j]>erformed  under  conditions  showing  that 
the  result  is  obviously  due  to  the  operation,  in  which  it  was  under- 
taken at  an  early  period  of  labor,  and  performed  with  a  reasonable 
amount  of  care,  it  is  obviously  impossible  to  arrive  at  any  reliable 
conclusions  as  to  the  mortality  of  the  operation."  By  the  sifting 
process,  carefully  and  conscientiously  performed,  I  am  able  to  furnish 
just  this  character  of  record,  the  operations  having  been  done  in  good 
season,  and  when  the  patients  were  not  endangered  by  previous  in- 
termeddling and  too  long  delay.  This  list  of  timely  operations  numbers 
27,  and  the  results  are  as  follows,  viz.:  women  saved,  20;  lost,  7; 
children  delivered  alive,  22,  of  whom  18  were  ultimately  saved;  and 
children  found  dead  in  utero,  5.  The  causes  of  death  in  the  seven 
were  as  follows,  viz.:  peritonitis,  3;  septicgemia,  1;  shock  and  ex- 
haustion (in  a  dwarf ),  1;  irritative  fever,  1;  and  intestinal  obstruc- 
tion, 1. 


CiESAREAN    SECTION.  523 

We  have,  then,  27  operations  of  the  class  called  for  by  the  author, 
and  these  are  all  that  can  be  claimed  out  of  the  112,  on  the  data 
found ;  there  may  possibl}^  have  been  one  or  two  more  iu  the  cases 
where  the  time  in  labor  has  not  been  ascertained,  judging  from  their 
saving  both  mother  and  child,  but  such  have  been  excluded  from  the 
list,  as  the  object  of  its  preparation  has  been  to  show  facts  without 
reference  to  result.  The  percentage  then  reads:  women  saved  under 
seasonably  perforwAid  Ceesarean  operations  in  the  United  States^  'i'^fi'i 
children  saved,  67-oV  j  children  rescued  alive,  and  dead  within  a 
week,  4  ;  whole  percentage  of  children  rescued  alive,  81  ^f.  To  show 
how  these  27  cases  represent  the  percentage  of  mortality,  I  have  just 
looked  back  in  my  record  eight  years,  when  the  list  of  operations 
numbered  59,  and  by  the  same  rule  of  exclusiveness  have  selected 
out  16  timely  oioerations.  By  these,  the  percentage  of  women  saved 
amounts  to  68|,  and  children  75.  During  the  eight  years,  I  have 
added  53  more  operations,  only  11  of  which  were  performed  in  due 
season,  either  as  to  time  or  condition,  and  we  find  an  improvement 
instead  of  a  diminution  in  the  favorable  result.  The  diminution  of 
the  proportion  of  timely  cases  is  explainable  from  the  fact  that  36  of 
the  53  additional  operations  had  been  withheld  from  publication,  and 
were  obtained  by  correspondence. 

One  of  the  most  celebrated  American  obstetrical  writers,  in  a  speech 
before  a  learned  medical  association,  delivered  a  year  ago,  claimed 
that  the  Ci^sarean  section  was  "the  most  dangerous  operation  in 
surgery."  Is  this  borne  out  by  the  facts  just  given?  Take  the 
capital  operations  of  surger}^,  and  hunt  them  everywhere,  frontier 
settlements  and  all,  and  how  many  will  show  -12  per  cent,  of  re- 
coveries? 

One  of  the  fallacies  which  is  contradicted  by  ovariotomy  every 
day  is,  that  the  great  danger  of  gastro-hysterotomy  is  the  opening  of 
the  abdominal  cavity.  When  Prof  Byford  performed  ovariotomy 
on  a  young  lady,^  and  followed  it  by  the  removal  of  a  seven  and  a 
half  months'  foetus  from  her  uterus,  having  thrown  it  into  contractile 
action  by  erroneously  tapping  it,  why  did  the  patient  make  a  good 
recovery?  Why,  also,  do  so  many  more  women  recover  after  an 
early  than  a  late  operation  ?  It  is  not  exhaustion  of  bodily  forces, 
for  we  see  this  in  many  ovariotomy  cases  that  do  well.  There  is 
but  one  way  to  account  for  it,  and  that  is  the  danger  of  opening  the 
uterus  after  it  has  been  long  in  action.  Uterine  muscular  fatigue 
favors  atony  of  the  organ,  gaping  of  the  incision  in  it,  the  escape  of 
blood  and  lochia  into  the  abdominal  cavity,  the  production  of  second- 
ary hemorrhage,  metro- peritonitis,  and  septicsemia,  and  the  condi- 
tions proving  fatal  under  the  names  of  shock,  exhaustion,  and  heart- 
clot.  We  hear  laparo-elytrotomy  commended  because  it  avoids 
opening  the,  abdominal  cavity,  when  its  real  value  is  in  avoiding  the 
uterine  incision  where  the  organ  has  been  permitted  to  exhaust 
itself  by  delay.  In  laparotomy  for  the  removal  of  an  extra-uterine 
foetus,  the  abdomen  is  opened,  and  many  cases  recover,  provided  the 

[1  Am.  Jour.  Obstetrics,  N.  Y.,  1879,  p.  31.] 


524  OBSTETRIC  OPERATIONS. 

placenta  is  not  removed  in  the  operation.  "What  has  made  the 
success  of  the  Porro  method,  but  the  recognition  of  the  fact  that  the 
uterus  is  the  seat  of  danger  ? 

Up  to  ten  or  twelve  years  ago,  the  general  result  of  the  CDesarean 
operations  of  the  United  States  put  us  very  much  in  advance  of  the 
success  attained  in  Grreat  Britain;  but  within  this  period  we  have 
been  decidedly  retrograding  and  England  slightly  improving.  Judg- 
ing from  the  past,  we  have  now  about  an  average  of  three  cases  a 
year.  In  the  whole  United  States,  we  have  saved  7  women  in  the 
last  decade,  out  of  32,  thereby  diminishing  the  percentage,  which 
stood  at  53  in  1869,  down  to  42f .  Having  become  frightened  at  the ' 
^^ dreadful'''  operation,  we  are  reaping  the  fruits  of  making  it  the 
'•'•forlorn  Ixoi^eP  With  the  exception  of  7  operated  on  early,  the 
women  were  in  labor  from  one  day  to  fifteen,  a  number  being  two, 
three,  and  four  days.  What  is  the  best  indication  of  the  character 
of  the  cases,  is  the  fact  that  21  of  the  32  children  were  lost. 

In  New  York  City,  one  surgeon  performed  the  operation  three 
times  in  as  many  consecutive  years,  and  lost  all  the  cases  because  of 
the  time  wasted  before  he  was  called  in.  Nos.  1  and  2  were  Germans, 
in  labor  three  days  each,  and  afiiected  with  pelvic  exostosis ;  both 
died,  and  one  child  lived.  No,  3  was  black,  with  a  deformed  pelvis, 
and  in  labor  four  days;  she  had  a  conjugate  of  1|  inch.  Of  these 
six  lives,  but  one  was  saved.  These  are  fair  examples  of  the  way 
in  which  time  is  wasted  in  useless  delay  on  the  part  of  accoucheurs 
and  midwives. 

The  Otesarean  operation  has  a  twofold  character  as  respects  the 
mortality  which  follows  it.  In  early  cases  it  is  an  expedient  of 
medium  gravity;  but  is  almost  hopeless  in  late  ones.  What  our 
accoucheurs  require,  is  to  realize  the  danger  of  delay  and  the  abso- 
lute necessity  of  haste.  The  erroneous  estimate  of  the  fatality  of  the 
operation  has  an  effect  to  insure  this  fatality  by  causing  delay  in  its 
performance.  I  was  recently  struck  with  the  remarkable  success  of 
an  operation  performed  by  Dr.  Olcott,  of  Brooklyn,  upon  a  woman 
in  whom  the  obstruction  to  delivery  was  a  large  uterine  fibroid, 
because  almost  all  such  cases  had  proved  fatal,  and  wrote  to  him  to 
know  exactly  how  long  it  was  after  the  commencement  of  labor  that 
he  began  to  operate.  His  answer,  "  nine  and  a  half  hours,"  revealed 
the  great  basis  of  his  success. — Ed.] 


LAPARO-ELYTKOTOMY,  525 


CHAPTER   YII. 

LAPAEO-ELYTROTOMY. 

In  the  former  editions  of  this  work  laparo-elytrotomy  was  briefly 
considered  as  one  of  the  suggested  substitutes  for  the  Cuisarean  section 
which  merited  careful  study,  and  appeared  to  be  of  a  promising 
character,  but  of  whicli  too  little  was  known  to  justify  anj^  positive 
conclusions  with  regard  to  it.  The  subject  naturally  attracted  con- 
siderable attention,  and  several  interesting  papers  have  appeared  in 
which  its  indications,  difficulties,  and  advantages  have  been  carefully 
considered.  Since  Thomas's  first  case  was  published,  several  operations 
have  been  performed,  with  results  so  encouraging  that  I  cannot  but 
believe  that  the  operation  has  a  great  future  before  it,  and  that  it 
will  be  the  duty  of  the  accoucheurs  to  resort  to  it  instead  of  the  more 
hazardous  Ciesarean  section,  unless  some  special  contra-indication 
exists.  Under  these  circumstances  it  seems  proper  no  longer  to 
consider  it  as  an  addendum  to  his  description  of  the  Ccesarean  sec- 
tion, but  to  study  it  more  in  detail  in  a  separate  chapter. 

History. — The  history  of  the  operation  is  curious  and  interesting. 
The  earliest  suggestion  of  a  procedure  of  this  character  seems  to 
have  been  made  by  Joerg  in  the  year  1806,  who  proposed  a  modi- 
fied Oeesarean  section,  without  incision  of  the  uterus,  by  the  division 
of  the  linea  alba,  and  of  the  upper  part  of  the  vagina,  the  foetus 
being  extracted  through  the  cervix.  This  suggestion  was  never 
carried  into  practice,  and  it  is  obvious  that  it  misses  the  one  chief 
advantage  of  laparo-elytrotomy,  the  leaving  of  the  peritoneum  intact. 
In  1820  Eitgen  proposed,  and  actually  attempted,  an  operation  much 
resembling  Thomas's,  in  which  section  of  the  peritoneum  was  avoided. 
He  failed,  however,  to  complete  it,  and  was  eventually  compelled  to 
deliver  his  patient  by  the  Cgesarean  section.  In  1823  Baudelocque, 
the  younger,  independently  conceived  the  same  idea,  and  actually 
carried  it  into  practice,  although  Avithout  success.  Lastly,  in  1837, 
Sir  Charles  Bell  suggested  a  similar  operation,  clearly  perceiving  its 
advantages.  Hence  it  appears  that  previous  to  Thomas's  recent  work 
in  the  matter,  the  operation  was  independently  invented  no  less  than 
three  times.  It  fell,  however,  entirely  into  oblivion,  and  was  onlv 
occasionally  mentioned  in  systematic  works  as  a  matter  of  curious 
obstetric  history,  no  one  apparently  appreciating  the  promising  char- 
acter of  the  procedure. 

In  the  year  1870,  Dr.  T.  Gaillard  Thomas,  of  New  York,  read  a 
paper  before  the  Medical  Association  of  the  town  of  Yonkers  on  the 
Hudson  River  entitled  "Gastro-elytrotomy,  a  substitute  for  the  Cesa- 
rean section,"  in  which  he  described  the  operation  as  he  had  per- 


526  OBSTETRIC    OPERATIONS. 

formed  it  three  times  on  tlie  dead  subject,  and  once  on  a  married 
woman  in  1870,  with  asuccessfal  issac  as  regards  the  child.  It  seems 
beyond  doubt  tliat  Thomas  invented  the  operation  for  liimself,  being 
ignorant  of  Eitgen's  and  Baudelocque's  previous  attempts,  and  it  is 
certain,  to  quote  Garrigues,^  that  to  him  "  belongs  the  glory  of  having 
been  the  first  who  performed  gastro-elytrotomy  so  as  to  extract  a  living 
child  from  a  living  mother  in  his  first  operation,  and  of  having 
brought  both  mother  and  child  to  complete  recovery  in  his  second 
operation." 

Since  Thomas's  first  case,  the  operation  has  been  performed  three 
times  by  Dr.  Skene  of  Brooklyn,  and  has  found  its  way  across  the 
Atlantic,  having  been  twice  performed  in  England,  by  Himes  in 
Shefiield,  and  by  Edis  in  London. 

Nature  of  the  Operation. — The  object  of  gastro-elytrotomy  is  to 
reach  the  cervix  by  incision  through  the  lower  part  of  the  abdominal 
wall,  and  upper  part  of  the  vagina,  and  through  it  to  extract  the 
foetus  as  may  most  easily  be  done. 

Advantages  over  the  Csesarean  Section. — If  this  procedure  is  found 
practicable,  the  enormous  advantages  it  offers  over  the  Csesarean 
section  are  at  once  apparent  in  dividing  the  abdomen,  the  abdominal 
wall  only  is  incised,  and  the  peritoneum  is  left  intact.  The  vagina  is 
divided,  but  incision  of  the  uterine  parietes,  which  forms  one  of  the 
chief  risks  of  the  Cassarean  section,  is  entirely  avoided.  ISTow  there 
is  nothing  in  either  of  these  procedures  alarming  in  itself,  and  if 
farther  experience  proves  that  the  practical  difficulties  of  the  opera- 
tion do  not  stand  in  the  way  of  its  adoption.  Dr.  Thomas  will  have 
introduced  by  his  able  advocacy  of  the  operation,  probably  the 
greatest  improvement  in  modern  obstetrics. 

Cases  suitable  for  the  Operation. — It  may  be  broadly  stated  that 
gastro-elytrotomy  is  applicable  in  all  cases  calling  for  the  Cesarean 
section, when  the  mother  is  alive.  In  post-mortem  extractions  of  the 
foetus,  the  Cassarean  section,  being  the  most  rapid  procedure,  would 
certainly  be  preferable.  Exceptions  must  be  made  for  certain  cases 
of  morbid  conditions  of  the  soft  parts  which  render  delivery  per  vias 
naturales  impossible,  and  in  which  gastro-elytrotomy  could  not  be 
performed,  where  it  would  be  impossible  in  cases  of  tumor  obstruct- 
ing the  pelvic  cavity,  also  in  carcinoma  or  fibroid  of  the  uterus. 
When  the  head  is  firmly  impacted  in  the  pelvic  brim,  and  cannot 
be  dislodged,  the  operation  would  be  impossible,  as  the  vagina  could 
not  be  incised.  Unlike  the  Cissarean  section,  the  operation  cannot 
be  performed  twice  on  the  same  patient,  at  least  on  the  same  side, 
since  adhesions  left  by  the  former  incisions  would  prevent  the  sepa- 
ration of  the  peritoneum,  and  division  of  the  vagina.  It  remains  to 
be  seen  whether  in  certain  cases  of  extreme  deformity,  with  pendu- 
lous abdomen  and  distorted  thighs,  the  site  of  the  incision  might  not 
be  so  difficult  to  reach,  as  to  render  the  necessary  manoeuvres  impos- 
sible. 

Anatomy  of  the  Parts  Concerned  in  the  Operation. — It  will  facilitate 

1  New  York  Med.  Jouru.,  Nov.  1878. 


LAPARO-ELYTROTOMY.  527 

the  proper  comprehension  of  the  operation,  and  render  an  avoidance 
of  its  possible  dangers  more  easy,  if  the  anatomical  relations  of  the 
parts  concerned  are  briefly  described. 

Abdominal  IiLcision. — The  abdominal  incision  extends  from  a  point 
an  inch  above  the  anterior  superior  iliac  spine,  and  is  carried,  with  a 
slight  downward  curve,  parallel  to  Poupart's  ligament,  until  it  reaches 
a  point  one  inch  and  three-quarters  above,  and  to  the  outside  of,  the 
spine  of  the  pubes.  Beyond  the  latter  point  it  must  not  extend,  so 
as  to  avoid  the  risk  of  wounding  the  round  ligament  and  the  epi- 
gastric artery.  In  this  incision  the  skin,  the  aponeurosis  of  the 
external  oblique,  and  the  fibres  of  the  internal  oblique,  and  trans- 
versalis  mascles,  are  divided.  The  rectus  is  not  implicated.  After 
the  muscles  are  divided,  the  transversalis  fascia  is  reached.  It  is 
fortunately  rather  dense  in  this  situation,  and  is  separated  from  the 
peritoneum  by  a  layer  of  connective  tissue  containing  fat. 

Arteries. — The  superficial  epigastric  artery  is  necessarily  divided, 
but  is  too  small  to  give  any  trouble.  The  internal  epigastric  is  fortu- 
nately not  divided,  but  is  so  near  the  inner  end  of  the  incision,  that  it 
may  accidentally  be  so.  In  one  of  Dr.  Skene's  operations  it  was 
laid  bare.  Starting  from  the  external  iliac,  about  a  quarter  of  an 
inch  above  Poupart's  ligament,  it  runs  downwards,  forwards,  and 
inwards  to  the  ligament,  thence  it  turns  upwards  and  inwards,  in 
front  of  the  round  ligament  and  inside  the  internal  abdominal  ring, 
behind  the  posterior  layer  of  the  sheaths  of  the  rectus  muscle,  which 
it  finally  enters.  The  circumflex  ilii  artery  also  rises  from  the  ex- 
ternal iliac  a  little  below  the  epigastric.  It  runs  between  the  perito- 
neum and  Poupart's  ligament  until  it  reaches  the  crest  of  the  ilium, 
inside  which  it  runs.  It  thus  lies  altogether  below  the  line  of  the 
incision,  and  is  not  likely  to  be  injured. 

Peritoneum. — 'After  the  transversalis  fascia  is  divided,  the  perito- 
neum is  reached,  and  is  readily  lifted  up  intact,  so  as  to  expose  the 
upper  parts  of  the  vagina,  through  which  the  foetus  is  extracted.  It 
is  fortunate,  as  facilitating  this  manoeuvrCj  that  the  peritoneum  is 
much  more  lax  than  in  the  non- pregnant  state,  and  it  has  been  found 
very  easy  to  lift  it  out  of  the  way  in  all  the  operations  hitherto  per- 
formed. 

Yccjinal  Incisions. — ^The  division  of  the  vagina  is  the  part  of  the 
operation  likely  to  give  rise  to  most  trouble  and  risk.  It  is  to  be 
noted,  that  in  cases  of  pelvic  contraction  calling  for  this  operation, 
the  uterus,  with  its  contents,  will  be  abnormally  high  and  altogether 
above  the  pelvic  brim  ;  the  vagina  is,  therefore,  necessarily  elongated 
and  brought  more  readily  within  reach.  It  is  enlarged  in  its  upper 
part  during  pregnancy,  and  thrown  into  folds  ready  for  dilatation 
during  the  passage  of  the  child.  It  is  loosely  surrounded  by  another 
tissue,  and  is  composed  of  muscular  fibres,  easily  separable,  and  an 
internal  mucous  layer.  Its  vascular  arrangements  are  very  complex, 
and  the  risk  of  hemorrhage  is  one  of  the  prominent  difficulties  of  the 
operation. 

In  Baudelocque's  attempt,  in  which  the  vagina  was  cut  instead  of 
torn,  the  loss  of  blood  was  so  great  as  to  lead  to  a  discontinuance  of 


528  OBSTETRIC  OPERATIONS. 

the  operation.  The  arteries  are  numerous,  consisting  of  branches 
from  the  hypogastric,  inferior  vesical,  internal  pudic,  and  haemor- 
rhoidal  arteries.  The  veins  form  a  network  surrounding  the  whole 
canal,  but  are  largest  at  its  extremities,  so  that  it  is  desirable  to  open 
the  vagina  as  low  down  as  possible. 

Relations  of  the  Vagina. — Behind  the  vagina  lies  the  pouch  of 
peritoneum  known  as  Douglas's  space,  and  below  that  the  rectum. 
In  front  of  it  lies  the  bladder,  and  the  risk  of  injuring  that  viscus, 
or  the  ureter  entering  it,  constitutes  another  of  the  dangers  of  the 
operation.  The  relations  of  these  parts  have  been  specially  studied 
by  Garrigues,^  with  the  view  of  facilitating  the  safe  performance  of 
the  operation,  and  I  quote  his  description. 

"  The  anterior  superior  surface  of  the  vagina  is,  in  its  upper  part, 
bound  by  loose  connective  tissue  to  the  bladder  on  a  surface  that  has 
the  shape  of  a  heart.  In  the  lower  or  anterior  part,  the  boundary 
line  of  this  surface  runs  parallel  to,  and  a  little  outside  of  the  trigo- 
num  vesicale.  In  the  upper  pa.rt  it  follows  the  outline  of  the  vagina, 
from  which  it  passes  over  to  the  cervix.  The  distance  from  the 
internal  opening  of  the  urethra  to  the  neck  of  the  womb  is  one  inch 
and  a  quarter  (3.2  centimetres).  The  bladder  extends  five-eighths 
of  an  inch  (1.5  centimetres)  upon  the  cervix.  It  is  very  liable  to  be 
reached  by  the  vaginal  rent,  if  the  latter  is  made  too  high  up  or  too 
horizontal.  The  lower  part  of  the  antero-superior  wall  carries  in  the 
middle  line  the  urethra.  In  the  uppermost  part,  a  little  outside  of, 
and  behind  the  bladder,  lies  the  ureter.  In  order  to  avoid  the  ureter 
and  the  bladder,  the  incision  of  the  vagina  should  be  made  nearly 
an  inch  and  a  half  (3.8  centimetres)  below  the  uterus,  and  in  a 
direction  parallel  to  the  ureter  and  the  boundary  line  between  the 
bladder  and  the  vagina." 

The  Operation. — The  operation  has  hitherto  been  performed  on  the 
right  side  only.  In  consequence  of  the  position  of  the  rectum  on  the 
left,  it  seems  doubtful  if  the  difficulties  of  performing  it  on  that 
side  would  not  render  the  operation  impossible.  This  point  can  only 
be  cleared  up  by  experience,  and,  in  the  mean  time,  the  right  side  should 
certainly  be  selected.  For  the  proper  performance  of  the  operation 
four  assistants  are  necessary,  besides  one  who  administers  the  anees- 
thetic.  The  patient  is  placed  on  her  back  on  the  operating  table, 
with  pelvis  raised,  and  in  the  same  position  for  ovariotomy.  In  con- 
sequence of  access  of  air  per  vaginam  strict  antiseptic  precautions 
cannot  be  adopted.  Before  commencing  the  operation  the  cervix  is 
dilated  as  much  as  possible  by  Barnes's  bags,  assisted,  if  necessary,  by 
digital  dilatation. 

The  operator  stands  on  the  right  side  of  the  patient,  while  an 
assistant,  standing  on  her  left,  lays  his  hands  on  the  uterus  and  draws 
it  upwards  and  to  the  left,  so  as  to  put  the  skin  on  the  stretch.  The 
incision  is  commenced  at  a  point  one  inch  above  the  anterior  superior 
spine  of  the  ilium,  and  is  carried  inwards,  in  a  slightly  curved  direc- 
tion, until  it  reaches  a  point  one  and  three-quarter  inch  above  and 

1  Loc.  cit.,  p.  479. 


LAPARO-ELYTROTOMY.  629 

outside  the  spine  (jf  tlie  pubes.  Tiie  slcin  and  muscular  and  aponeu- 
rotic tissues  are  carefully  divided,  layer  by  layer,  any  arterial  branches 
being  secured  as  they  are  severed,  until  the  transversalis  fascia  is 
reached.  This  is  raised  by  a  line  tenaculum,  and  an  aperture  is  made 
in  it,  through  which  a  director  is  introduced,  and  on  this  the  fascia 
is  divided  in  the  whole  length  of  the  superficial  incision.  The  opera- 
tor now  separates  the  peritoneum  from  the  transversalis  and  iliac 
fascia  with  his  fingers,  and  an  assistant,  placed  on  his  left,  elevates 
it,  as  well  as  the  contained  intestines,  by  means  of  a  fine  warmed 
napkin  and  keeps  it  well  out  of  the  way  during  the  rest  of  the  opera- 
tion. A  third  assistant  now  introduces  a  silver  catheter  into  the 
bladder,  and  holds  it  in  the  position  of  the  boundary  line  between  it 
and  the  vagina,  and  below  the  uterus. 

A  blunt  wooden  instrument  like  the  obturator  of  a  speculum  is 
introduced  into  the  vagina,  which  is  pushed  up  by  it  above  the  ilio- 
pectineal  line.  On  this  an  incision  is  made  by  Paquelin's  thermo- 
cautery heated  to  a  red  heat  only,  as  far  below  the  uterus  as  possible, 
and  parallel  to  the  ilio-pectineal  line  and  the  catheter  felt  in  the 
bladder.  When  the  vagina  has  been  burnt  through,  the  index  fingers 
of  both  hands  are  pushed  through  the  incision,  and  the  vagina  torn 
through  as  far  forward  as  is  deemed  safe  by  the  guide  of  the  catheter 
in  the  bladder,  and  as  far  backward  as  possible.  When  this  has  been 
done  the  uterus  is  depressed  to  the  left,  and  the  cervix  lifted  into  the 
incision  by  the  fingers,  and  the  membranes  are  ruptured.  Through 
the  cervix  thus  elevated  the  child  is  extracted,  according  to  the  pre- 
sentation, either  by  simple  traction,  by  the  forceps,  or  by  turning. 
Before  concluding  the  operation  the  bladder  should  be  injected  with 
milk,  to  make  sure  that  it  has  not  been  wounded.  Should  it  be  so, 
the  laceration  may  be  at  once  united  by  carbolized  gut.  The  prin- 
cipal risk  at  this  stage  is  hemorrhage  from  the  vaginal  vessels,  which, 
however,  fortunately  did  not  give  rise  to  much  trouble  in  any  of  the 
recent  operations.  If  it  occurs  it  must  be  dealt  with  as  best  we  can, 
either  by  ligature,  by  the  actual  cautery,  or  by  thoroughly  plugging 
the  vaginal  wound  with  cotton-wool  both  through  the  incision  and 
per  vaginam.  If  the  latter  is  not  necessary  the  wound  should  be 
cleaned  by  injecting  a  warm  solution  of  weak  carbolized  water  (2  per 
cent.),  its  edges  united  by  interrupted  sutures,  and  dressed  as  is  deemed 
best.  The  subsequent  treatment  must  be  conducted  on  general  sur- 
gical principles,  and  will  much  resemble  that  necessary  after  other 
severe  abdominal  operations,  such  as  ovariotomy.  The  vagina  should 
be  gently  syringed  two  or  three  times  daily  with  a  weak  antiseptic 
lotion.  The  diet  should  be  mild  and  nutritious,  chiefly  consisting  of 
milk,  beef-tea,  and  the  like.  Pain,  pyrexia,  etc.,  must  be  treated  as 
they  arise. 

[I  have  little  to  add  in  reference  to  this  scientific,  but  difiicult 
operation,  which  must  be  necessarily  limited  in  its  adoption,  because 
of  the  skill  and  number  of  assistants  wdiich  it  requires,  and  the  many 
cases  in  which  it  is  inadmissible.  In  45  out  of  the  112  Cesarean 
cases  in  my  record,  it  could  n'ot  have  been  performed.  Seven  opera- 
tions in  nine  years  is  very  slow  progress,  compared  with  the  Porro 


530  OBSTETRIC    OPERATIONS. 

method,  as  shown  by  the  reports  of  the  latter  from  the  Continent, 
where  it  is  now  being  performed  on  an  average  of  about  once  a  month, 
and  with  a  degree  of  success  more  satisfactory  than  is  shown  by  the 
record  of  the  Thomas  method.  The  anatomical  skill  demanded, 
together  with  its  other  requirements,  will  necessarily  confine  Laparo- 
elytrotomy  to  our  large  cities,  and  limit  the  great  future  which  has 
been  anticipated  for  it.  It  has  by  no  means  as  yet  had  a  full  trial. 
—El).] 


CIIAPTEE  YIIL 

THE  TRANSFUSION  OF  BLOOD. 

The  transfusion  of  blood  in  desperate  and  apparently  hopeless 
cases  of  hemorrhage,  offers  a  possible  means  of  rescuing  the  patient 
which  merits  careful  consideration.  It  has  again  and  again  attracted 
the  attention  of  the  profession,  but  has  never  become  popularized  in 
obstetric  practice.  The  reason  of  this  is  not  so  much  the  inherent 
defects  of  the  operation  itself — for  quite  a  sufficient  number  of  suc- 
cessful cases  are  recorded  to  make  it  certain  that  it  is  occasionally  a 
most  valuable  remedy — but  the  fact  that  the  operation  has  been  con- 
sidered a  delicate  and  difficult  one,  and  that  it  has  been  deemed 
necessary  to  employ  complicated  and  expensive  ayjparatus,  which  is 
never  at  hand  when  a  sudden  emergency  arises.  Whatever  may  be 
the  difference  of  opinion  about  the  value  of  transfusion,  I  think  it 
must  be  admitted  that  it  is  of  the  utmost  consequence  to  simplify 
the  process  in  every  possible  way,  and  it  is  above  all  things  neces- 
sary to  show  that  the  steps  of  the  operation  are  such  as  can  be  readily 
performed  by  any  ordinarily-qualified  practitioner,  and  that  the  ap- 
paratus is  so  simple  and  portable  as  to  make  it  easy  for  any  obstetri- 
cian to  have  it  at  hand.  There  are  comparatively  few  who  would 
consider  it  worth  while  to  carry  about  with  them,  in  ordinary  every- 
day work,  cumbrous  and  expensive  instruments  which  may  never  be 
required  in  a  life-long  practice ;  and  hence  it  is  not  unlikely  that,  m 
many  cases  in  which  transfusion  might  have  proved  useful,  the  op- 
portunity of  using  it  has  been  allowed  to  slip.  Of  late  years  the 
operation  has  attracted  much  attention,  the  method  of  performing  it 
has  been  greatly  simplified,  and  I  think  it  Avill  be  easy  to  prove  that 
all  the  essential  apparatus  may  be  purchased  for  a  few  shillings,  and 
in  so  portable  a  form  as  to  take  up  little  or  no  room ;  so  that  it 
may  be  always  carried  in  the  obstetric  bag  ready  for  any  possible 

emergency. 

The  history  of  the  operation  is  of  considerable  interest.  In  Yillari's 
"  Life  of  Savonarola"  it  is  said  to  have  been  employed  in  the  case  of 
Pope  Innocent  YIIL,  in  the  year  1492,  but  I  am  not  aware  on  what 


THE    TRANSFUSION    OF    BLOOD.  531 

authority  the  statement  is  made.  The  first  serious  proposals  for  its 
performance  do  not  seem  to  have  been  made  until  the  latter  half  of 
the  seventeenth  century.  It  was  first  actually  performed  in  France, 
by  Denis,  of  Montpellier,  although  Lower,  of  Oxford,  had  previously 
made  experiments  on  animals  which  satisfied  him  that  it  might  be 
undertaken  with  success.  In  November,  1G07,  some  months  after 
Denis's  case,  he  made  a  public  experiment  at  Arundel  House,  in 
which  twelve  ounces  of  sheep's  blood  were  injected  into  the  veins  of 
a  healthy  man,  who  is  stated  to  have  been  very  well  after  the  opera- 
tion, which  must,  therefore,  have  proved  successful.  These  nearly 
simultaneous  cases  gave  rise  to  a  controversy  as  to  priority  of  inven- 
tion, which  was  long  carried  on  with  much  bitterness. 

The  idea  of  resorting  to  transfusion  after  severe  hemorrhage  does 
not  seem  to  have  been  then  entertained.  It  was  recommended  as  a 
means  of  treatment  in  various  diseased  states,  or  with  the  extrava- 
gant hope  of  imparting  new  life  and  vigor  to  the  old  and  decrepit. 
The  blood  of  the  lower  animals  only  was  used ;  and,  under  these  cir- 
cumstances, it  is  not  surprising  that  the  operation,  although  practised 
on  several  occasions,  was  never  established  as  it  might  have  been 
had  its  indications  been  better  iinderstood. 

From  that  time  it  fell  almost  entirely  into  oblivion,  although  ex- 
periments and  suggestions  as  to  its  applicability  were  occasionally 
made,  especially  by  Dr.  Harwood,  Professor  of  Anatomy  at  Cam- 
bridge, who  published  a  thesis  on  the  subject  in  the  year  1785.  He, 
however,  never  carried  his  suggestions  into  practice,  and,  like  his 
predecessors,  only  proposed  to  employ  blood  taken  from  the  lower 
animals.  In  the  year  1824  Dr.  Blundell  published  his  well-known 
worls,  entitled  "  Researches,  Physiological  and  Pathological,"  which 
detailed  a  large  number  of  experiments ;  and  to  that  distinguished 
physician  belongs  the  undoubted  merit  of  having  brought  the  subject 
prominently  before  the  profession,  and  of  pointing  out  the  cases  in 
which  the  operation  might  be  performed  with  hopes  of  success. 
Since  the  publication  of  this  work,  transfusion  has  been  regarded  as 
a  legitimate  operation  under  special  circumstances ;  but,  although  it 
has  frequently  been  performed  with  success,  and  in  spite  of  many  in- 
teresting monographs  on  the  subject,  it  has  never  become  so  estab- 
lished, as  a  general  resource  in  suitable  cases,  as  its  advantages  would 
seem  to  warrant.  Within  the  last  few  years  more  attention  has  been 
paid  to  the  subject,  and  the  writing  of  Panum,  Martin,  and  de  Belina, 
abroad,  and  of  Higginson,  McDonnell,  Hicks,  and  Aveling  at  home, 
amongst  many  others,  have  thrown  much  light  on  many  points  con- 
nected with  the  operation,  and  it  is  to  be  hoped  that  the  committee 
appointed  by  the  Obstetrical  Society,  in  their  forthcoming  report, 
may  still  more  increase  our  knowledge. 

Nature  and  Object  of  the  Operation. — Transfusion  is  practically  only 
employed  in  cases  of  profuse  hemorrhage  connected  with  labor,  al- 
though it  has  been  suggested  as  possibly  of  value  in  certain  other 
puerperal  conditions,  such  as  eclampsia,  or  puerperal  fever.  Theo- 
retically it  may  be  expected  to  be  useful  in  such  diseases;,  but,  inas- 
much as  little  or  nothing  is  known  of  its  practical  effects  in  these 


532  OBSTETRIC  OPERATIONS. 

diseased  states,  it  is  onlj  possible  here  to  discuss  its  use  in  cases  of 
excessive  liemorrliage.  Its  action  is  probablj  twofold.  1st,  the 
actual  restitution  of  blood  which  has  been  lost.  2d,  the  supply  of  a 
sufficient  quantity  of  blood  to  stimulate  the  heart  to  contraction,  and 
thus  to  enable  the  circulation  to  be  carried  on  until  fresh  blood  is 
formed.  The  influence  of  transfusion  as  a  means  of  restoring  lost 
blood  must  be  trivial,  since  the  quantity  required  to  produce  an  effect 
is  generally  very  small  indeed,  and  never  sufficient  to  counterbalance 
that  which  has  been  lost.  Its  stimulant  action  is  no  doubt  of  far 
more  importance  ;  and  if  the  operation  be  performed  before  the 
vital  energies  are  entirely  exhausted,  the  effect  is  often  most  marked. 

Use  of  Blood  taken  from  the  Lower  Animals. — In  the  earliest  opera- 
tions the  blood  used  was  always  that  of  the  lower  animals,  generally 
of  the  sheep.  Dr.  Blundell  believed  that  such  blood  could  not  be 
employed  with  success.  Recent  cases,  such  as  those  published  by 
Keene,  who  used  lamb's  blood  in  12  cases.^  have  conclusively  proved 
this  idea  to  be  erroneous.  Brown-Sequard  has  shown  that  Blundell's 
experiments  with  animal  blood  failed,  partly  because  he  used  too 
large  a  quantity  and  injected  too  quickly,  and  partly  because  he  used 
blood  too  rich  in  carbonic  acid  and  too  poor  in  oxygen.  He  has 
shown  that  the  success  of  the  operation  must  depend  to  a  great  ex- 
tent on  these  points,  and  that  blood,  containing  sufficient  carbonic 
acid  to  be  black,  proves  directly  poisonous,  unless  it  is  injected  in 
very  small  quantity,  and  with  great  slowness.  Although,  then,  it 
is  certain  that  the  blood  of  some  of  the  lower  animals,  especially  of 
those  in  which  the  corpuscles  are  of  less  size  than  in  man,  as  in  sheep, 
can  be  employed  with  safety,  still  the  operation,  of  late  years,  has 
been  almost  always  performed  with  human  blood  alone,  and,  for 
many  obvious  reasons,  is  always  likely  to  be  so. 

Difficulties  from  Coagulation  of  Fihrine.- — The  great  practical  diffi- 
culty in  transfusion  has  always  been  the  coagulation  of  the  blood 
very  shortly  after  it  has  been  removed  from  the  body.  When  fresh 
drawn  blood  is  exposed  to  the  atmosphere,  the  fibrine  commences  to 
solidify  rapidly,  generally  in  from  three  to  four  minutes,  sometimes 
much  sooner.  It  is  obvious  that  the  moment  fibrination  has  com- 
menced the  blood  is,  ijyso  facto.^  unfitted  for  transfusion,  not  only  be- 
cause it  can  be  no  longer  passed  readily  through  the  injecting  appa- 
ratus, but  because  of  the  great  danger  of  propelling  small  masses  of 
iibrine  into  the  circulation,  and  thus  causing  embolism.  PEence,  if  no 
attempt  be  made  to  prevent  this  difficulty,  it  is  essential,  no  matte? 
what  apparatus  is  used,  to  hurry  on  the  operation  so  as  to  inject  be 
fore  fibrination  has  begun.  This  is  a  fatal  objection,  for  there,  is  no 
operation  in  the  whole  range  of  surgery  in  which  calmness  and  de= 
liberation  are  so  essential,  the  more  so  as  the  surroundings  of  the 
patient  in  these  unfortunate  cases  are  such  as  to  tax  the  presence 
of  mind  and  coolness  of  the  practitioner  and  his  assistants  to  the 
utmost. 

Methods  of  Ohviatinfj  Coagulation. — All  the  recent  improvements 

'  London  Med.  Record,  Dec.  ol,  1873. 


THE    TRANSFUSION    OF    BLOOD.  633 

have  had  for  their  object  the  avoidance  of  coagulation,  and  practi- 
cally this  has  been  effected  in  one  of  three  ways.  1st,  by  immediate 
transfusion  from  arm  to  arm,  without  allowing  the  blood  to  be  ex- 
posed to  the  atmosphere,  according  to  the  methods  proposed  by 
Aveling  and  Roussel.  2d,  by  adding  to  the  blood  certain  chemical 
reagents  which  have  the  property  of  preventing  coagulation.  8d, 
removal  of  the  fibrine  entirely,  by  promoting  its  coagulation  and 
straining  the  blood,  so  that  the  liquor  sanguinis  and  blood  corpuscle 
alone  are  injected. 

Inasmuch  as  the  success  of  the  operation  altogether  depends  on 
the  method  adopted,  it  will  be  well,  before  going  further,  to  consider 
briefly  the  advantages  and  disadvantages  of  each  of  these  plans. 

Immediate  Transfusion. — 1.  The  method  of  immediate  transfusion 
has  been  brought  prominently  before  the  profession  by  Dr.  Aveling, 
who  has  invented  an  ingenious  apparatus  for  performing  it.  The 
apparatus  consists  essentially  of  a  miniature  Higginson's  syringe, 
without  valves,  and  with  a  small  silver  canula  at  either  end.  One 
canula  is  inserted  into  the  vein  of  the  person  supplying  blood,  the 
other  into  a  vein  of  the  patient,  and  by  a  peculiar  manipulation  of 
the  syringe,  subsequently  to  be  described,  the  blood  is  carried  from 
one  vein  into  the  other.  It  must  be  admitted  that,  if  there  were  no 
practical  difficulties,  this  instrument  would  be  admirable,  and  it  is 
therefore  not  surprising  that  it  should  have  met  with  go  much  favor 
from  the  profession.  I  cannot  but  think,  however,  that  the  opera- 
tion is  not  so  simple  as  it  at  first  sight  appears,  and  that  therefore  it 
wants  one  of  the  essential  elements  required  in  any  procedure  for 
performing  transfusion.  One  of  my  objections  is,  that  it  is  by  no 
means  easy  to  work  the  apparatus  without  considerable  practice. 
Of  this  I  have  satisfied  myself  by  asking  members  of  my  class  to 
work  it  after  reading  the  printed  directions,  and  finding  that  they 
are  not  always  able  to  do  so  at  once.  Of  course  it  may  be  said  that 
it  is  easy  to  acquire  the  necessary  manipulative  skill;  but,  when  the 
necessity  for  transfusion  arises,  there  is  no  time  left  for  practising 
with  the  instrument,  and  it  is  essential  that  an  apparatus,  to  be  uni- 
versally applicable,  should  be  capable  of  being  used  immediately, 
and  without  previous  experience.  Other  objections  are  the  necessity 
of  several  assistants,  the  uncertainty  of  there  being  a  sufficient  circu- 
lation of  blood  in  the  veins  of  the  donor  to  aff"ord  a  constant  supply, 
and  the  possibility  of  the  whole  apparatus  being  disturbed  by  rest- 
lessness or  jactitation  on  the  part  of  the  patient.  For  these  reasons, 
it  seems  to  me  that  this  plan  of  immediate  transfusion  is  not  so 
simple,  nor  so  generally  applicable,  as  defibrination.  Still,  it  is  im- 
possible not  to  recognize  its  merits,  and  it  is  certainly  well  worthy 
of  further  study  and  investigation. 

Another  method  of  immediate  transfusion  is  that  recommended 
by  RousseV  whose  apparatus  has  recently  attracted  considerable 
attention.  It  possesses  many  undoubted  advantages,  and  is,  beyond 
doubt,  a  valuable  addition  to  our  means  of  performing  the  opera- 

'  Obstetrical  Transactions,  vol.  xviii. 


534  OBSTETRIC  OPERATIONS. 

tiou.  It  has,  however,  the  great  disadvantage  of  being  costly  and 
complicated,  aad  hence  I  do  not  believe  that  it  is  likely  to  come  into 
general  use. 

Addition  of  Chemical  Agents  to  Prevent  Coagulation. — 2.  The  second 
plan  for  obviating  the  bad  effects  of  clotting  is  the  addition  of  some 
substance  to  the  bh^od  which  shall  prevent  coagulation.  It  is  well 
known  that  several  salts  have  this  property,  and  the  experiments 
made  in  the  case  of  cholera  patients  prove  that  solutions  of  some  of 
tbem  may  be  injected  into  the  venous  system  without  injury.  This 
method  has  been  specially  advocated  by  Dr.  Braxton  Hicks,  who 
uses  a  solution  of  three  ounces  of  fresh  phosphate  of  soda  in  a  pint 
of  water,  about  six  ounces  of  wbich  are  added  to  the  quantity  of 
blood  to  be  injected.  He  has  narrated  4  cases^  in  which  this  plan 
was  adopted  successfully,  so  far  as  the  prevention  of  coagulation  was 
concerned.  It  certainly  enables  the  operation  to  be  performed  with 
deliberation  and  care,  but  it  is  somewhat  complicated;  and  it  may 
often  happen  that  the  necessary  chemicals  are  not  at  hand.  A  further 
objection  is  the  balk  of  fluid  which  must  be  injected,  and  there  is 
reason  to  believe  that  this  has,  in  some  cases,  seriously  embarrassed 
the  heart's  action,  and  interfered  with  the  success  of  the*  operation. 
In  many  of  the  successful  cases  of  transfusion  the  amount  of  blood 
injected  has  been  very  small,  not  more  than  two  ounces.  Dr. 
Eichardson  proposes  to  prevent  coagulation  by  the  addition  of 
liquor  ammonias  to  the  blood,  in  the  proportion  of  two  minims, 
diluted  with  twenty  minims  of  water,  to  each  ounce  of  blood. 

Defibrination  of  the  Blood. — 3.  The  last  method,  and  the  one  which, 
on  the  whole,  I  believe  to  be  the  simplest  and  most  effectual,  is  defi- 
brination. It  has  been  chiefly  practised  in  this  country  by  Dr. 
McDonnell,  of  Dublin,  who  has  published  several  very  interesting 
cases  in  which  he  employed  it,  and  abroad  by  Martin,  of  Berlin ;  de 
Belina,  of  Paris  [and  Thomas  G.  Morton,  of  Philadelphia.^  Dr. 
Morton  has  transfused  defibrinated  blood  fourteen  times  in  twelve 
subjects;  in  one  of  them  with  an  interval  of  a  month  between  the 
two  operations.  The  cases  were  exhaustion  after  hemorrhage,  pro- 
found anaemia,  exhaustion  at  close  of  typhoid  fever,  purpura  hgsmor- 
rhagica,  and  opium  poisoning.— Ed.],  The  process  of  removing  the 
fibrine  is  simple  in  the  extreme,  and  occupies  a  few  minutes  only. 
Another  advantage  is  that  the  blood  to  be  transfused  may  be  pre- 
pared quietly  in  an  adjoining  apartment,  so  that  the  operation  may 
be  performed  with  the  greatest  calmness  and  deliberation,  and  the 
donor  is  spared  the  excitement  and  distress  which  the  sight  of  the 
apparently  moribund  patient  is  apt  to  cause,  and  which,  as  Dr.  Hicks 
has  truly  pointed  out,  may  interfere  with  the  free  flow  of  blood. 
The  researches  of  Panum,  Brown-Sdquard,  and  others,  have  proved 
that  the  blood  corpuscles  are  the  true  vivifying  element,  and  that 
defibrinated  blood  acts  as  Avell,  in  every  respect,  as  that  containing 

'  Guy's  Hosp.  Reports,  vol.  xiv, 

[2  See  Am.  Jour.  Med.  Sci.,  .July,  1874,  p.  110,  Article  VII.,  by  Dr.  Thomas  G. 
Morton  ;  with,  reports  of  cases  and  designs  of  apparatus  employed. — Ed.] 


THE    TRANSFUSION    OF    BLOOD.  535 

fibrine.  It  has  been  proved  that  the  fibrine  is  reproduced  within  a 
short  time/  and  the  whole  tendency  of  modern  research  is  to  regard 
it,  not  as  an  essential  element  of  the  blood,  but  as  an  excrementitious 
product,  resulting  from  the  degradation  of  tissue,  which  may,  there- 
fore, be  advantageously  removed.  Another  advantage  derived  from 
defibrination  is,  that  the  corpuscles  are  freely  exposed  to  the  atmo- 
sphere, oxygen  is  taken  up,  and  carbonic  acid  given  off",  and  the 
dangers  which  Brown-Sequard  has  shown  to  arise  from  the  use  of 
blood  containing  too  much  carbonic  acid  are  thereby  avoided.  There 
can  be,  therefore,  no  physiological  objection  to  the  removal  of  the 
fibrine,  which,  moreover,  takes  away  all  practical  difficulty  from  the 
operation.  The  straining  to  which  the  defibrinated  blood  is  sub- 
jected entirely  prevents  the  possibility  of  even  the  most  minute 
particle  of  fibrine  being  contained  in  the  injected  fluid;  the  risk 
from  embolism  is,  therefore,  less  than  in  any  of  the  other  processes 
already  referred  to.  My  own  experience  of  this  plan  is  limited  to  8 
cases,  but  in  2  it  answered  so  well  that  I  can  conceive  no  reasonable 
objection  to  it.  I  should  be  inclined  to  say  that  transfusion,  thus 
performed,  is  amongst  the  simplest  of  surgical  operations — an  opinion 
Avhich  the  experience  of  McDonnell  and  others  fully  confirms. 

Transfusion  of  Milk. — Eecently  the  intra- venous  injection  of  freshly 
drawn  warm  milk  has  been  recommended  as  a  substitute  for  blood, 
chiefly  in  America.  It  was  first  used  by  Dr.  Hodder  of  Toronto,  but 
has  been  introduced  and  strongly  advocated  by  Thomas  of  New  York, 
who  has  used  it  twice  after  ovariotomy.  Brown-S^quard  in  experi- 
menting on  the  lower  animals  found  that  it  answered  as  well  as  either 
fresh  or  defibrinated  blood,  and  about  half  an  hour  after  the  injection 
no  trace  of  the  milk-corpuscles  could  be  found  in  the  blood.  It  pos- 
sesses the  advantage  of  being  more  easily  obtained,  and  more  readily 
manipulated  than  blood,  but  future  researches  are  required  before  its 
perfect  efficacy  can  be  considered  established.  About  .Iviij  of  milk 
are  sufficient  for  ordinary  cases,  and  it  should  be  fresh  draAvn,  warm, 
and  free  from  acidity. 

[In  the  last  edition,  I  introduced  a  long  article  upon  the  "intra- 
venous injection  of  rhilk,"  in  place  of  which  the  author  has  prepared 
the  above.  As  he  gives  no  account  of  the  process,  I  reproduce  the 
statement  of  Dr.  Charles  T.  Hunter,  of  the  University  of  Pennsylvania, 
Avho  has  performed  the  operation  ten  times  on  four  subjects. 

The  milk  is  drawn  into  a  double  vessel,  with  warm  water  in  the 
interspace,  and  the  temperature  regulated  to  about  99°  Fahr.  The 
fluid  is  strained  through  fine-wire-gauze,  to  exclude  any  foreign 
matters  that  might  be  injurious.  Attached  to  the  funnel  and  tube 
Dr.  Hunter  has  a  perforating  canula  with  a  small  stopcock  to  cut  oft" 
the  flow  of  milk.  After  the  vein  is  fully  exposed,  the  milk  is  run 
through  the  tube,  the  cock  closed,  which  keeps  the  canula  full  by 
capillary  attraction,  and  the  vessel  perforated  by  the  cutter  on  the 
end  of  the  canula;  the  cock  is  then  opened,  funnel  elevated,  and  milk 
carried  in  by  its  own  weight. — Ed.] 

'  Panum,  Virchow's  Arch.,  vol.  xxvii. 


536  OBSTETRIC  OPERATIONS. 

Statisiical  Results. — The  number  of  cases  of  transfusion  are  perhaps 
not  sufficient  to  admit  of  completely  reliable  conclusions.  It  is  cer- 
tain, however,  that  transfusion  has  often  been  the  means  of  rescuing 
the  patient  when  apparently  at  the  point  of  death,  and  after  all  other 
means  of  treatment  had  failed.  Professor  Martin  records  67  cases, 
in  43  of  which  transfusion  was  completely  successful,  and  in  7  tem- 
porarily so ;  while  in  the  remaining  7  no  reaction  took  place.  Dr. 
Higginson,  of  Liverpool,  has  had  15  cases,  10  of  which  were  success- 
ful. Figures  such  as  these  are  encouraging,  and  they  are  sufficient 
to  prove  that  the  operation  is  one  which  at  least  offers  a  fair  hope  of 
success,  and  which  no  obstetrician  would  be  justified  in  neglecting, 
when  the  patient  is  sinking  from  the  exhaustion  of  profuse  hemor- 
rhage. It  is  to  be  hoped  also  that  further  experience  may  prove  it 
to  be  of  value  in  other  cases,  in  which  its  use  has  been  suggested, 
but  not,  as  yet,  put  to  the  test  of  experiment. 

Possible  Dangers  of  the  Operation. — The  possible  risks  of  the  opera- 
tion would  seem  to  be  the  danger  of  injecting  minute  particles  of 
fiibrine  which  form  emboli,  of  bubbles  of  air,  or  of  overwhelming  the 
action  of  the  heart  by  injecting  too  rapidly,  or  in  too  great  quantity. 
These  may  be,  to  a  great  extent,  prevented  by  careful  attention  to 
the  proper  performance  of  the  operation,  and  it  does  not  clearly 
appear,  from  the  recorded  cases,  they  have  ever  proved  fatal.  We 
must  also  bear  in  mind  that  transfusion  is  seldom  or  ever  likely  to 
be  attempted  until  the  patient  is  in  a  state  which  would  otherwise 
almost  certainly  preclude  the  hope  of  recovery,  and  in  which,  there- 
fore, much  more  hazardous  proceedings  would  be  fully  justified. 

Gates  Suitable  for  Transfusion. — The  cases  suitable  for  transfusion 
are  those  in  which  the  patient  is  reduced  to  an  extreme  state  of 
exhaustion  from  hemorrhage  during  or  after  labor  or  miscarriage, 
whether  by  the  repeated  losses  of  placenta  praevia,  or  the  more 
sudden  and  profuse  flooding  of  post-partum  hemorrhage.  The  opera- 
tion will  not  be  contemplated  until  other  and  simpler  means  have 
been  tried  and  failed,  or  until  the  symptoms  indicate  that  life  is  on 
the  verge  of  extinction.  If  the  patient  should  be  deadly  pale  and 
cold,  with  no  pulse  at  the  wrist,  or  one  that  is  scarcely  perceptible ; 
if  she  be  unable  to  swallow,  or  vomits  incessantly  ;  if  she  lie  in  an 
unconscious  state;  if  jactitation,  or  convulsions,  or  repeated  fainting 
should  occur ;  if  the  respiration  be  laborious,  or  very  rapid  and 
sighing;  if  the  pupil  do  not  act  under  the  influence  of  light,  it  is 
evident  that  she  is  in  a  condition  of  extreme  danger,  and  it  is,  under 
such  circumstances,  that  transfusion,  performed  sufficiently  soon, 
offers  a  fair  prospect  of  success.  It  does  not  necessarily  follow  be- 
cause one  or  other  of  these  symptoms  is  present,  that  there  is  no 
chance  of  recovery  under  ordinary  treatment,  and  indeed  it  is  within 
the  experience  of  all,  that  patients  have  rallied  under  apparently  the 
most  hopeless  conditions.  But  when  several  of  them  occur  together, 
the  prospect  of  recovery  is  much  diminished,  and  transfusion  would 
then  be  fully  justified,  especially  as  there  is  no  reason  to  think  that 
a  fatal  result  has  ever  been  directly  traced  to  its  employment.  In- 
deed, like  most  other  obstetric  operations,  it  is   more  likely  to  be 


THE    TRANSFUSION    OF    BLOOD. 


637 


postponed  until  too  late  to  be  of  service,  tlian  to  be  employed  too 
early ;  and  in  some  of  the  cases  reported  as  unsuccessful,  it  was  not 
performed  until  respiration  had  ceased,  and  death  had  actually  taken 
place.  It  has  been  sometimes  said  that  transfusion  can  never  be 
employed  if  the  uterus  be  not  firmly  contracted,  so  as  to  prevent  the 
injected  blood  again  escaping  through  the  uterine  sinuses.  The  cases 
in  which  this  is  likely  to  occur  are  few ;  and  if  one  were  met  with, 
the  escape  of  blood  could  be  prevented  by  the  injection  into  the 
uterus  of  the  perchloride  of  iron. 

Description  of  the  Operation, — In  describing  the  operation  I  shall 
limit  myself  to  an  account  of  Aveling's  method  of  immediate  trans- 
fusion, and  to  that  of  injecting  defibrinatcd  blood.  I  consider  myself 
justified  in  omitting  any  account  of  the  numerous  apparatuses  which 
have  been  invented  for  the  purpose  of  injecting  pure  blood,  since  I 
believe  the  practical  difficulties  are  too  great  ever  to  render  this  form 
of  operation  serviceable.  The  great  objection  to  most  of  the  instru- 
ments used  is  their  cost  and  complexity  :  and  as  long  as  any  special 
apparatus  is  considered  essential,  the  full  benefits  to  be  derived  from 
transfusion  are  not  likely  to  be  realized.  The  necessity  for  employ- 
ing it  arises  suddenly ;  it  inay  be  in  a  locality  in  which  it  is  impossi- 
ble to  procure  a  special  instrument ;  and  it  would  be  well  if  it  were 
understood  that  transfusion  may  be  safely  and  effectually  performed 
by  the  simplest  means.  In  many  of  the  successful  cases  an  ordinary 
syringe  was  used ;  in  one,  in  the  absence  of  other  instruments,  a 
child's  toy  syringe  was  employed.  I  have  myself  performed  it  with 
a  simple  syringe  purchased  at  the  nearest  chemist's  shop,  when  a 
special  transfusion  apparatus  failed  to  act  satisfactorily. 

Method  of  performing  Immediate  Transfusion. — In  immediate  trans- 
fusion (Fig.  181),  the  donor  is  seated  close  to  the  patient,  and  the 


Fig.  181. 


Method  of  Transfusion  by  Aveliug's  Apparatus. 


veins  in  the  arms  of  each  having  been  opened,  the  silver  canula  at 
either  end  of  the  instrument  in  introduced  into  them  (a  b).  The  tube 
between  the  bulb  and  the  patient  is  now  pinched  (d),  so  as  form  a 
vacuum,  and  the  bulb  becomes  filled  with  blood  from  the  donor. 
35 


538  OBSTETRIC  OPERATIONS. 

The  finger  is  now  removed  so  as  to  eompress  the  distal  tube  (d'), 
aud  the  bulb  being  compressed  (c),  its  contents  are  injected  into  the 
patient's  vein.  The  bulb  is  calculated  to  hold  about  two  drachms, 
so  that  the  amount  injected  can  be  estimated  by  the  number  of  times 
it  is  emptied.  The  risk  of  injecting  air  is  prevented  by  filling  the 
syringe  with  water,  which  is  injected  before  the  blood. 

Injection  of  Befibrinated  BIood.—Fov  injecting  defibrinated  blood 
various  contrivances  have  been  used.  McDonnell's  instrument  is  a 
simple  cylinder  with  a  nozzle  attached,  from  which  the  blood  is  pro- 
pelled by  gravitation.  When  the  propulsive  power  is  insufficient, 
increased  pressure  is  applied  by  breathing  forcibly  into  the  open  end 
of  the  receiver.  De  Belina's  instrument  is  on  the  same  principle, 
only  atmospheric  pressure  is  supplied  by  a  contrivance  similar  to 
Kichardson's  spray -producer,  attached  to  one  end.  The  idea  is  simple, 
but  there  is  some  doubt  of  a  gravitation  instrument  being  sufficiently 
powerful,  and  it  certainly  failed  in  my  hands.  I  have  had  valves 
applied  to  Aveling's  instrument,  so  that  it  works  by  compression  of 
the  bulb,  like  an  ordinary  Higginson's  syringe.  This,  with  a  single 
silver  canula  at  one  end,  for  introduction  into  the  vein,  forms  a  per- 
fect and  inexpensive  transfusion  apparatus,  taking  up  scarcely  any 
space.  If  it  be  not  at  hand,  any  small  syringe,  with  a  tolerably  fine 
nozzle,  may  be  used. 

Mode  of" Preparing  the  Blood. — The  first  step  of  the  operation  is 
defibrination  of  the  blood,  which  should,  if  possible,  be  prepared  in 
an  apartment  adjoining  the  patient's.  The  blood  should  be  taken 
from  the  arm  of  a  strong  and  health}^  man.  The  quality  cannot  be 
unimportant,  and,  in  some  recorded  cases,  the  failure  of  the  operation 
has  been  attributed  to  the  fact  of  the  donor  having  been  a  weakly 
female.  The  supply  from  a  woman  might  also  prove  insufliicient ; 
and,  although  it  has  been  shown  that  blood  from  two  or  more  per- 
sons may  be  used  with  safety,  yet  such  a  change  necessarily  causes 
delay,  and  should,  if  possible,  be  avoided.  A  vein  having  been 
opened,  eight  or  ten  ounces  of  blood  are  withdraAvn,  and  received 
into  some  perfectly  clean  vessel,  such  as  a  dessert  finger-glass.  As  it 
flows  it  should  be  briskly  agitated  Avith  a  clear  silver  fork,  or  a  glass 
rod,  and  very  shortly,  strings  of  fibrine  begin  to  form.  It  is  now 
strained  through  a  'piece  of  fine  muslin,  previously  dipped  in  hot 
water,  into  a  second  vessel  which  is  floating  in  water  at  a  tempera- 
ture of  about  105°.  By  this  straining  the  fibrine  and  air-bubbles 
resulting  from  the  agitation  are  removed,  and,  if  there  be  no  exces- 
sive hurry,  it  might  be  well  to  repeat  the  straining  a  second  time.  If 
the  vessel  be  kept  floating  in  warm  water,  the  blood  is  prevented 
from  getting  cool,  and  we  can  now  proceed  to  prepare  the  arm  of  the 
patient  for  injection. 

Mode  of  Exposing  the  Veins  selected  for  Transfusion. — This  is  the 
most  delicate  and  difficult  part  of  the  operation,  since  the  veins  are 
generally  collapsed  and  empty,  and  by  no  means  easy  to  find.  The 
best  way  of  exposing  them  is  that  practised  by  McDonnell,  who 
pinches  up  a  fold  of  the  skin  at  the  bend  of  the  elbow,  and  transfixes 
it  with  a  fine  tenotomy  knife  or  scalpel,  so  making  a  gaping  wound 


THE    TRANSFUSION    OF    BLOOD.  539 

in  the  integument,  at  the  bottom  of  which  they  are  seen  Iving.  A 
probe  should  now  be  passed  underneath  the  vein  selected  for  opening, 
so  as  to  avoid  the  chance  of  its  being  lost  at  any  subsequent  stage  of 
the  operation.  This  is  a  point  of  some  importance,  and  from  the 
neglect  of  this  precaution  I  have  been  obliged  to  open  another  vein 
than  that  originally  fixed  on,  A  small  portion  of  the  vein  being 
raised  with  the  forceps,  a  nick  is  made  into  it  for  the  passage  of  the 
canula.. 

Injection  of  the  Blood. — The  prepared  blood  is  now  brought  to  the 
bedside,  and,  the  apparatus  having  been  previously  filled  with  blood 
to  avoid  the  risk  of  injecting  any  bubbles  of  air,  the  canula  is  in- 
serted into  the  opening  made  in  the  vein,  and  transfusion  commenced. 
It  should  be  constantly  borne  in  mind  that  this  part  of  the  operation 
should  be  conducted  with  the  greatest  caution,  the  blood  introduced 
very  slowly,  and  the  effect  on  the  patient  carefully  watched.  The 
injection  may  be  proceeded  with  until  some  perceptible  effect  is  pro- 
duced, which  will  generally  be  a  return  of  the  pulsation,  first  at  the 
heart,  and  subsequently  at  the  wrist,  an  increase  in  the  temperature 
of  the  body,  greater  depth  and  frequency  of  the  respirations,  and  a 
general  appearance  of  returning  animation  about  the  countenance. 
Sometimes  the  arms  have  been  thrown  about,  or  spasmodic  twitch- 
ings  of  the  face  have  taken  place.  The  quantity  of  blood  required 
to  produce  these  effects  varies  greatly,  but  in  the  majority  of  cases 
has  been  very  small.  Occasionally  2  ounces  have  proved  sufficient, 
and  the  average  may  be  taken  as  ranging  between  4  and  6  :  although 
in  a  few  cases  between  10  and  20  have  been  used.  The  practical 
rule  is  to  proceed  very  slowly  with  the  injection  until  some  per- 
ceptible result  is  observed.  Should  embarrassed  or  frequent  respira- 
tion supervene,  we  may  snspect  that  we  have  been  injecting  either 
too  great  a  quantity  of  blood,  or  with  too  much  force  and  rapidity, 
and  the  operation  should  at  once  be  suspended,  and  not  resumed  until 
the  suspicious  symptoms  have  passed  away.  It  may  happen  that  the 
effects  of  the  transfusion  have  been  highly  satisfactory,  but  that  in 
the  course  of  time  there  is  evidence  of  returning  syncope.  This  may 
possibly  be  prevented  by  the  administration  of  stimulants ;  but  If 
these  fail  there  is  no  reason  why  a  fresh  supply  of  blood  should  not 
again  be  injected,  but  this  should  be  done  before  the  effects  of  the 
first  transfusion  have  entirely  passed  away. 

Secondary  Effects  of  Transfusion. — The  subsequent  effects  in  suc- 
cessful cases  of  transfusion  merit  careful  study.  In  some  few  cases 
death  is  said  to  have  happened  within  a  few  weeks,  with  symptoms 
resembling  pyaemia.  Too  little  is  known  on  this  point,  however,  to 
justify  any  positive  conclusions  with  regard  to  it. 


PART  Y. 

THE  PUERPERAL  STATE. 


CHAPTER  I. 

THE   PUERPERAL    STATE    AND   ITS    MANAGEMENT. 

Importance  of  Studying  the  Puerperal  State. — The  key  .to  the  man- 
agement of  women  after  labor,  and  to  the  proper  understanding  of 
the  many  important  diseases  which  may  then  occur,  is  to  be  found 
in  a  study  of  the  phenomena  following  delivery,  and  of  the  changes 
going  on  in  the  mother's  system  during  the  puerperal  period.  No 
doubt  natural  labor  is  a  physiological  and  healthy  function,  and 
during  recovery  from  its  effects  disease  should  not  occur.  It  must 
not  be  forgotten,  however,  that  none  of  our  patients  are  under  phy- 
siologically healthy  conditions.  The  surroundings  of  the  lying-in 
woman,  the  effects  of  civilization,  of  errors  of  diet,  of  defective  clean- 
liness, of  exposure  to  contagion,  and  of  a  hundred  other  conditions, 
which  it  is  impossible  to  appreciate,  have  most  important  influences 
on  the  results  of  childbirth.  Hence  it  follows  that  labor,  even  under 
the  most  favorable  conditions,  is  attended  with  considerable  risk. 

The  Mortality  of  Ghildhirth.- — It  is  not  easy  to  say  with  accuracy 
what  is  the  precise  mortality  accompanying  childbirth  in  ordinary 
domestic  practice,  since  the  returns  derived  from  the  reports  of  the 
Registrar-General,  or  from  private  sources,  are  manifestly  open  to 
serious  error.  Tlie  nearest  approach  to  a  reliable  estimate  is  that 
made  by  Dr.  Matthews  Duncan,^  who  calculates  from  figures  derived 
from  various  sources,  that  not  fewer  than  1  out  of  every  120  women, 
delivered  at  or  near  the  full  time,  dies  within  four  weeks  of  child- 
birth. This  indicates  a  mortality  far  above  that  which  has  been 
generally  believed  to  accompany  child-bearing  under  favorable  cir- 
cumstances. It,  however,  closely  approximates  to  a  similar  estimate 
made  by  McClintock,^  who  calculates  the  mortality  in  England  and 
Wales  as  1  in  126;  and  in  the  upper  and  middle  classes  alone,  where 
the  conditions  may  naturally  be  supposed  to  be  more  favorable,  at  1 
in  146 ;  more  recently  he  has  come  to  the  conclusion  from  his  own 
increased  experience,  and  the  published  results  of  the  practice  of 
others,  that  1  in  100  would  more  correctly  represent  the  rate  of  puer- 
peral mortality.^    In  these  calculations  there  are  some  obvious  sources 

»  The  "Mortality  of  Childbed,"  Edin.  Med.  Journ.,  Nov.  1869. 
2  Dublin  Quarterly  Journ.,  Aug.  1869.  »  Brit.  Med.  Journ.,  Aug,  10,  1878. 

(640) 


THE    PUEllPERAL    STATE    AND    ITS    MANAGEMENT.  541 

of  error,  since  tliey  include  deaths  from  all  causes  witliin  four  weeks 
of  deliver}',  some  of  which  must  liave  been  independent  of  the  puer- 
peral state. 

But  it  is  not  the  deaths  alone  which  should  be  considered.  All 
practitioners  know  how  large  a  number  of  their  patients  suffer  from 
morbid  states  which  may  be  directly  traced  to  the  eiiects  of  child- 
bearing.  It  is  impossible  to  arrive  at  any  statistical  conclusion  on 
this  point,  but,  it  must  have  a  wery  sensible  and  important  influence 
on  the  health  of  child-bearing  women. 

Alterations  in  the  Blood  after  Delivery. — The  state  of  the  blood 
daring  pregnancy,  already  referred  to,  has  an  important  bearing  on 
the  puerperal  state.  There  is  liyperinosis,  which  is  largely  increased 
by  the  changes  going  on  immediately  after  the  birth  of  the  child : 
for  then  the  large  supply  of  blood,  which  has  been  going  to  the  uterus, 
is  suddenly  stopped,  and  the  system  must  also  get  rid  of  a  quantity 
of  effete  matter  thrown  into  the  circulation,  in  consequence  of  the 
degenerative  changes  occurring  in  the  muscular  fibres  of  the  uterus. 
Hence  all  the  depurative  channels,  by  which  this  can  be  eliminated, 
are  called  on  to  act  with  great  activity.  If,  in  addition,  the  peculiar 
condition  of  the  generative  tract  be  borne  in  mind — viz.,  the  large 
open  vessels  on  its  inner  surface — -the  partially  bared  inner  surface 
of  the  uterus,  and  the  channels  for  absorjjtion  existing  in  consequence 
of  slight  lacerations  in  the  cervix  or  vagina — it  is  not  a  matter  of 
surprise  that  septic  diseases  should  be  so  common. 

Condition  after  Delivery. — It  will  be  well  to  conr>ider  successively 
the  various  changes  going  on  after  delivery,  and  then  we  shall  be  in 
a  better  position  for  studying  the  rational  management  of  the  puer- 
peral state. 

Nervous  Shock. — Some  degree  of  nervous  shock  or  exhaustion  is 
observable  after  most  labors.  In  many  cases  it  is  entirely  absent ; 
in  others  it  is  well  marked.  Its  amount  is  in  proportion  to  the 
severity  of  the  labor,  and  the  susceptibility  of  the  patient ;  and  it  is 
therefore,  most  likely  to  be  excessive  in  women  who  have  suffered 
greatly  from  pain,  who  have  undergone  much  muscular  exertion,  or 
who  have  been  weakened  from  undue  loss  of  blood.  It  is  evidenced 
by  a  feeling  of  exhaustion  and  fatigue,  and  not  uncommonly  there 
is  some  shivering,  which  soon  passes  off,  and  is  generally  followed 
by  refreshing  sleep.  The  extreme  nervous  susceptibility  continues 
for  a  considerable  time  after  delivery,  and  indicates  the  necessity  of 
keeping  the  lying-in  patient  as  free  from  all  sources  of  excitement  as 
possible. 

Fall  of  the  Pulse. — Immediately  after  delivery  the  pulse  falls,  and 
the  importance  of  this,  as  indicating  a  favorable  state  of  the  patient, 
has  already  been  alluded  to.  The  condition  of  the  pulse  has  been 
carefully  studied  by  Blot,^  who  has  shown  that  this  diminution, 
which  he  believes  to  be  connected  with  an  increased  tension  in  the 
arteries,  due  to  the  sudden  arrest  of  the  uterine  circulation,  continues, 
in  a  large  proportion  of  cases,  for  a  considerable  number  of  days 

J  Arch.  Gen,  dc  Med.,  18G4. 


542  THE    PUERPERAL    STATE. 

after  delivery ;  and,  as  a  matter  of  clinical  import,  as  long  as  it  does, 
the  patient  may  be  considered  to  be  in  a  favorable  state.  In  many 
instances  the  slowness  of  the  pulse  is  remarkable,  often  sinking  to 
50  or  even  40  beats  per  minute.  Any  increase  above  the  normal 
rate,  especially  if  at  all  continuous,  should  always  be  carefully  noted, 
and  looked  on  with  suspicion.  In  connection  with  tliis  subject,  how- 
ever, it  must  be  remembered  that  in  puerperal  women  the  most 
trivial  circumstances  may  cause  a  sudden  rise  of  the  pulse.  This 
must  be  familiar  to  every  practical  obstetrician,  who  has  constant 
opportunities  of  observing  this  effect  after  any  transient  excitement 
or  fatigue.  In  lying-in  hospitals  it  has  generally  been  observed  that 
the  occurrence  of  any  particularly  bad  case  will  send  up  the  pulse  of 
all  the  other  patients  who  may  have  heard  of  it. 

Temj^erature  in  the  Puerperal  State. — The  temperature  in  the  lying- 
in  state  affords  much  valuable  information.  During,  and  for  a  short 
time  after  labor,  there  is  a  slight  elevation.  It  soon  falls  to,  or  even 
somewhat  below,  the  normal  level.  Squire  found  that  the  fall  oc- 
curred witliin  twenty-four  bours,  sometimes  within  twelve  hours, 
after  the  termination  of  labor..^  For  a  few  days  there  is  often  a 
slight  increase  of  temperature,  which  is  probabl}^  caused  by  the  rapid 
oxidation  of  tissue  in  connection  with  the  involution  of  the  uterus. 
In  about  forty-eight  hours  there  is  a  rise  connected  with  the  estab- 
lishment of  lactation,  amounting  to  one  or  two  degrees  over  the 
normal  level;  but  this  again  subsides  as  soon  as  the  milk  is  freely 
secreted.  Crede  has  also  shown^  that  rapid,  but  transient,  rises  of 
temperature  may  occur  at  any  period,  connected  with  trivial  causes, 
such  as  constipation,  errors  of  diet,  or  mental  disturbances.  But,  if 
there  be  any  rise  of  temperature  which  is  at  all  continuous,  especially 
to  over  100"  Fahr.,  and  associated  with  rapidity  of  the  pulse,  there 
is  reason  to  fear  the  existence  of  some  complication. 

The  Secretions  and  Excretions. — The  various  secretions  and  excre- 
tions are  carried  on  with  increased  activity  after  labor.  The  skin 
especially  acts  freely,  the  patient  often  sweating  profusely.  There 
is  also  an  abundant  secretion  of  urine,  but  not  uncommonly  a  diffi- 
cult}^ of  voiding  it,  either  on  account  of  temporary  paralysis  of  the 
neck  of  the  bladder,  resulting  from  the  pressure  to  which  it  has  been 
subjected,  or  from  swelling  and  occlusion  of  the  urethra.  For  the 
same  reason  the  rectum  is  sluggish  for  a  time,  and  constipation  is 
not  infrequent.  The  appetite  is  generally  indifferent,  and  the  patient 
is  often  thirsty. 

Secretion  of  Milk. — Generally  in  about  forty -eight  hours  the  secre- 
tion of  milk  becomes  established,  and  this  is  occasionally  accompanied 
by  a  certain  amount  of  constitutional  irritation.  The  breasts  often 
become  turgid,  hot,  and  painful.  There  may,  or  may  not,  be  some 
general  disturbance,  quickening  of  pulse,  elevation  of  temperature, 
possibly  slight  shivering,  and  a  general  sense  of  oppression,  which 
are  quicklv  relieved  as  the  milk  is  formed,  and  the  breasts  emptied 

'   "Puerperal  Temperatures,"  Obstetrical  Transactions,  vol.  ix. 
«  Monat.  f.  Geburt,  Dec.  1868. 


THE    PUERPERAL    STATE    AND    ITS    MANAGEMENT.  543 

by  suckling.  Squire  says  that  the  most  constant  phenomenon  con- 
nected with  tlie  temperature  is  a  slight  elevation  as  the  milk  is 
secreted,  rapidly  falling  when  lactation  is  established.  Bai-ker  noted 
elevation,  either  of  temperature  or  pulse,  in  only  4  out  of  52  cases 
which  were  carefully  watched.  There  can  be  little  doubt  that  the 
importance  of  the  so-called  "milk  fever"  has  been  immensely  ex- 
aggerated, and  its  existence,  as  a  normal  accompaniment  of  the 
puerperal  state,  is  more  than  doubtful.  It  is  certain,  however,  that, 
in  a  small  minority  of  cases,  there  is  an  appreciable  amount  of  dis- 
turbance about  the  time  that  the  milk  is  formed.  Out  of  428  cases 
Macan^  found  that  in  114,  or  about  27  per  cent.,  there  was  no  rise  of 
temperature  ;  in  226  the  temperature  did  rise  to  100^  and  over,  and 
of  these  in  32,  or  a  little  over  7  per  cent.,  the  only  ascertainable  cause 
was  a  painful  or  distended  condition  of  the  breast.  Many  modern 
writers,  such  as  Winckel,  Griinewaldt,  and  d'Espine,  entirely  deny 
the  connection  of  this  disturbance  with  lactation,  and  refer  it  to  a 
slight  and  transient  septicremia.  Graily  Hewitt  remarks  that  it  is 
most  commonly  met  with  when  the  patient  is  kept  low  and  on  defi- 
cient diet  after  delivery,  especially  when  the  system  is  below  par 
from  hemorrhage,  or  any  other  cause.  This  observation  will,  no 
doubt,  account  for  the  comparative  rarity  of  febrile  disturbance  in 
connection  with  lactation  in  these  days,  in  which  the  starving  of 
puerperal  patients  is  not  considered  necessary.  It  is  certain  that 
anything  deserving  the  name  of  milk  fever  is  now  altogether  excep- 
tional, and  such  feverishness  as  exists  is  generally  quite  transient. 
It  is  also  a  fact,  that  it  is  most  apt  to  occur  in  delicate  and  weakly 
women,  especially  in  those  who  do  not,  or  are  unable  to,  nurse. 
There  does  not,  however,  seem  to  be  any  sufficient  reason  for  refer- 
ring it,  even  when  tolerably  well  marked,  to  septicremia.  The  relief 
which  attends  the  emptying  of  the  breasts  seems  snfficient  to  prove 
its  connection  with  lactation,  and  the  discomfort  which  is  necessarily 
associated  with  the  swollen  and  turgid  mammte,  is,  of  itself,  quite 
sufficient  to  explain  it. 

In  the  urine  of  women  during  lactation  an  appreciable  amount  of; 
sugar  may  readily  be  detected.  The  amount  varies  according  to  the 
condition  of  the  breasts.  It  increases  Avhen  they  are  turgid  and  con- 
gested, and  is,  therefore,  most  abundant  in  women  in  whom  the  breasts 
are  not  emptied,  as  when  the  child  is  dead,  or  when  lactation  is  not 
attempted. 

Contraction  of  the  Uterus  after  Delivery. — Immediately  after  de- 
livery the  uterus  contracts  firmly,  and  can  be  felt  at  the  lower  part 
of  the  abdomen  as  a  hard,  firm  mass,  about  the  size  of  a  cricket  ball. 
After  a  time  it  again  relaxes  somewhat,  and  alternate  relaxations  and 
contractions  go  on,  at  intervals,  for  a  considerable  time  after  the 
expulsion  of  the  placenta.  The  more  complete  and  permanent  the 
contraction,  the  greater  the  safety  and  comfort  of  the  patient ;  for 
when  the  organ  remains  in  a  state  of  partial  relaxation,  coagula  are 
apt  to  be  retained  in  its  cavity,  while,  for  the  same  reason,  air  enters 

'  Dublin  Journ.  of  Med.  Science,  May,  1878. 


544  THE    PUERPERAL    STATE. 

more  readily  into  it.  Hence  decomposition  is  favored,  and  the  chances 
of  septic  absorption  are  much  increased ;  while,  even  when  this  does 
not  occur,  the  muscular  fibres  are  excited  to  contract,  and  severe 
after-pains  are  produced. 

Subsequent  I)iviinution  in  the  Size  of  the  Uterus. — After  the  first 
few  days  the  diminution  in  the  size  of  the  uterus  progresses  with 
great  rapidity.  By  about  the  sixth  day  it  is  so  much  lessened  as  to 
l^roject  not  more  than  IJ  or  2  inches  above  the  pelvic  brim,  while  by 
the  eleventh  day  it  is  no  longer  to  be  made  out  by  abdominal  palpa- 
tion. Its  increased  size  is,  however,  still  apparent  per  vaginara,  and, 
should  occasion  arise  for  making  an  internal  examination,  the  mass 
of  the  lower  segment  of  the  uterus,  with  its  flabby  and  patulous 
cervix,  can  be  felt  for  some  weeks  after  delivery.  This  may  some- 
times be  of  practical  value  in  cases  in  which  it  is  necessary  to  ascer- 
tain the  fact  of  recent  deliver}^,  and,  under  these  circumstances,  as 
'•  pointed  out  by  Simpson,  the  uterine  sound  would  also  enable  us  to 
prove  that  the  cavity  of  the  uterus  is  considerably  elongated.  Indeed 
the  normal  condition  of  the  uterus  aiud  cervix  is  not  regained  until 
six  weeks  or  two  months  after  labor.  These  observations  are  cor- 
roborated by  investigations  on  the  weight  of  the  organ  at  different 
periods  after  labor.  Thus  HeschP  has  shown  that  the  uterus,  imme- 
diately after  delivery,  weighs  about  22  to  24  oz. ;  within  a  week,  it 
weighs  19  to  21  oz. ;  and  at  the  end  of  the  second  week,  10  to  11 
oz.  only.  At  the  end  of  the  third  week,  it  weighs  5  to  7  oz. ;  but 
it  is  not  until  the  end  of  the  second  month  that  it  reaches  its  normal 
weight.  Hence  it  appears  that  the  most  rapid  diminution  occurs 
during  the  second  week  after  delivery. 

Fatty  Transformation  of  the  Muscular  Fibres. — The  mode  in  which 
this  diminution  in  size  is  effected  is  by  the  transformation  of  the 
muscular  fibres  into  molecular  fat,  which  is  absorbed  into  the  mater- 
nal vascular  system,  which,  therefore,  becomes  loaded  with  a  large 
amount  of  effete  material.  Heschl  has  shown  that  the  entire  mass 
of  the  enlarged  uterine  muscles  are  removed,  and  replaced  by  newly- 
formqd  fibres,  which  commence  to  be  developed  about  the  fourth 
week  after  delivery,  the  change  being  complete  about  the  end  of  the 
second  month.  Generally  speaking,  involution  goes  on  without  inter- 
ruption. It  is,  however,  apt  to  be  interfered  with  by  a  variety  of 
causes,  such  as  premature  exertion,  intercurrent  disease,  and,  very 
probably,  by  neglect  of  lactation.  Hence  the  uterus  often  remains 
large  and  bulky,  and  the  foundation  for  many  subsequent  uterine 
ailments  is  laid. 

Changes  in  the  Uterine  Vessels. — Williams  has  drawn  attention  to 
changes  occurring  in  the  vessels  of  the  uterus,  some  of  which'  seem 
to  be  permanent,  and  may,  should  further  observations  corroborate 
his  investigations,  prove  of  value  in  enabling  us  to  ascertain  whether 
a  uterus  is  nulliparous  or  the  reverse ;  a  question  which  may  be  of 
medico-legal  importa^ice.  After  pregnancy  he  found  all  the  vessels 
enlarged  in  calibre.     The  coats  of  the  arteries  are  thickened  and 

'  Researches  on  the  Conduct  of  the  Human  Uterus  after  Delivery. 


THE    PUERPERAL    STATE    AND    ITS    MANAGEMENT.  545 

hypertropliied,  and  tliis  he  has  observed  even  in  the  uteri  of  aged 
women  who  have  not  born  children  for  many  years.  The  venous 
sinuses,  especially  at  the  placental  site,  have  their  walls  greatly 
thickened  and  convoluted,  and  contain  in  their  centre  a  small  clot  of 
blood  (Fig.  182).     This  thickening  attains  its  greatest  dimensions  in 

Fig.  182. 


Section  of  a  Uterine  Sinus  from  the  Placental  Site  nine  weeks  after  Delivery.     (After  Williams.) 

the  third  month  after  gestation,  but  traces  of  it  may  be  detected  as 
late  as  ten  or  twelve  weeks  after  labor. 

Changes  in  the  Uterine  Mucous  Membrane. — The  changes  going  on 
in  the  lining  membrane  of  the  uterus  immediately  after  delivery  are 
of  great  importance  in  leading  to  a  knowledge  of  the  puerperal  state, 
and  have  already  been  discussed  when  describing  thedecidua  (p.  96). 
Its  cavity  is  covered  with  a  reddish-gray  film,  formed  of  blood  and 
fibrine.  The  open  mouths  of  the  uterine  sinuses  are  still  visible, 
more  especially  over  the  site  of  the  placenta,  and  thrombi  may  be 
seen  projecting  from  them.  The  placental  site  can  be  distinctly  made 
out,  in  the  form  of  an  irregularly  oval  patch,  where  the  lining  mem- 
brane is  thicker  than  elsewhere. 

Contraction  of  the  Vagina.,  etc. — The  vagina  soon  contracts,  and,  by 
the  time  the  puerperal  month  is  over,  it  has  returned  to  its  normal 
dimensions,  but  after  child-bearing  it  always  remains  more  lax,  and 
less  rugose,  than  in  nulliparae.  The  vulva,  at  first  very  lax  and 
much  distended,  soon  regains  its  former  state.  The  abdominal  pari- 
etes  remain  loose  and  flabby  for  a  considerable  time,  and  the  white 
streaks,  produced  by  the  distension  of  the  cutis,  very  generally  be- 
come permanent.    In  some  women,  especially  when  proper  support 


546  THE    PUERPERAL    STATE. 

bj  bandaging  has  not  been  given,  the  abdomen  remains  permanently- 
loose  and  pendulous. 

The  Lochial  Discharge. — From  the  time  of  delivery,  up  to  about 
three  weeks  afterwards,  a  discharge  escapes  from  the  interior  of  the 
uterus,  known  as  the  lochia.  At  first  this  consists  almost  entirely  of 
pure  blood,  mixed  with  a  variable  amount  of  coagula.  If  efficient 
uterine  contraction  have  not  been  secured  after  the  expulsion  of  the 
placenta,  coagula  of  considerable  size  are  frequently  expelled  with 
the  lochia  for  one  or  two  days  after  delivery.  In  three  or  four  days 
the  distinctly  bloody  character  of  the  lochia  is  altered.  They  have 
a  reddish  watery  appearance,  and  are  known  as  the  lochia  rubra  or 
cruenta.  According  to  the  researches  of  Wertheimer,^  they  are  at 
this  time  composed  chiefly  of  blood  corpuscles,  mixed  with  epithelium 
scales,  mucous  corpuscles,  and  the  debris  of  the  decidua.  The  change 
in  the  appearance  of  the  discharge  progresses  gradually,  and  about 
the  seventh  or  eight  day  it  has  no  longer  a  red  color,  but  is  a  pale 
greenish  fluid,  with  a  peculiar  sickeniag  and  disagreeable  odor,  and 
is  familiarly  described  as  the  "green  waters."  It  now  contains  a 
smaller  quantity  of  blood  corpuscles,  which  lessen  in  amount  from 
day  to  day,  but  a  considerable  number  of  pus  corpuscles,  which  re- 
main the  principal  constituent  of  the  discharge  until  it  ceases.  Besides 
these,  epithelial  scales,  fatty  granules,  and  crystals  of  cholesterine, 
are  observed.  Occasionally  a  small  infusorium,  which  has  been 
named  the  "trichomena  vaginalis,"  has  been  detected  ;  but  it  is  not 
of  constant  occurrence. 

Variation  in  its  Amount  and  Duration.- — The  amount  of  the  lochia 
varies  much,  and  in  some  women  it  is  habitually  more  abundant 
than  in  others.  Under  ordinary  circumstances  it  is  very  scanty  after 
the  first  fortnight,  but  occasionally  it  continues  somewhat  abundant 
for  a  month  or  more,  without  any  bad  results.  It  is  apt  again  to 
become  of  a  red  color,  and  to  increase  in  quantity,  in  consequence 
of  an}^  slight  excitement  or  disturbance.  If  this  red  discharge  con- 
tinue for  any  undue  length  of  time,  there  is  reason  to  suspect  some 
abnormality,  and  it  may  not  unfrequently  be  traced  to  slight  lacera- 
tions about  the  cervix,  which  have  not  healed  properly.  This  result 
may  also  folloAv  premature  exertion,  interfering  with  the  proper  in- 
volution of  the  uterus;  and  the  patient  should  certainly  not  be 
allowed  to  move  about  as  long  as  much  colored  discharge  is  going  on. 

Occasional  Fetor  of  the  Discharge. — Occasionally  the  lochia  have 
an  intensely  fetid  odor.  This  must  always  give  rise  to  some  anxiety, 
since  it  often  indicates  the  retention  and  putrefaction  of  coagula,  and 
involves  the  risk  of  septic  absorption.  It  is  not  ver}'  rare,  however, 
to  observe  a  most  disagreeable  odor  persist  in  the  lochia  without  any 
bad  results.  The  fetor  always  deserves  careful  attention,  and  an 
endeavor  should  be  made  to  obviate  it  by  directing  the  nurse  to 
syringe  out  the  vagina  freely  night  and  morning  with  Condy's  fluid 
and  water;    while,  if  it  be  associated    with   quickened   pulse   and 

'  Vircliow's  Arch.,  1861. 


THE    PUERPERAL    STATE    AND    ITS    MANAGEMENT.  647 

elevated  temperature,  other  measures,  to  be  subsequently  described, 
will  be  necessary. 

The  after -'pains,  wliich  many  child-bearing  women  dread  even 
more  than  the  labor-pains,  arc  irregular  contractions,  occurring  for 
a  varying  time  after  delivery,  and  resulting  from  the  efforts  of  the 
uterus  to  expel  coagula  which  have  formed  in  its  interior.  If,  there- 
fore, special  care  be  taken  to  secure  complete  and  permanent  con- 
traction after  labor,  tlic}^  rarely  occur,  or  to  a  very  slight  extent. 
Their  dependence  on  uterine  inertia  is  evidenced  by  the  common 
observation  that  they  are  seldom  met  with  in  primiparoB,  in  whom 
uterine  contraction  may  be  supposed  to  bo  more  efficient,  and  are 
most  frequent  in  women  who  have  borne  many  children.  They  are 
a  preventible  complication,  and  one  which  need  not  give  rise  to  any 
anxiety;  they  arc,  indeed,  rather  salutary  than  the  reverse,  for  if 
coagula  be  retained  in  utero,  the  sooner  they  are  expelled  the  better. 
The  after-pains  generally  begin  a  few  hours  after  delivery,  and  con- 
tinue in  bad  cases,  for  three  or  four  days,  but  seldom  longer.  They 
are  generally  increased  when  the  mammce  are  irritated  by  suction. 
When  at  their  height  they  are  often  relieved  by  the  expulsion  of  the 
coagula.  In  some  severe  cases  they  are  apparently  neuralgic  in 
character,  and  do  not  seem  to  depend  on  the  retention  of  coagula. 
They  may  be  readily  distinguished  from  pains  due  to  more  serious 
causes,  by  feeling  the  enlarged  uterus  harden  under  their  influence, 
by  the  uterus  not  being  tender  on  pressure,  and  by  the  absence  of 
any  constitutional  symptoms. 

Manageinent  of  Women  after  Delivery  .-—^he.  management  of  women 
after  child-birth  has  varied  much  at  different  times,  according  to 
fashion  or  theory.  The  dread  of  inflammation  long  influenced  the 
professional  mind,  and  caused  the  adoption  of  a  strictly  antiphlo- 
gistic diet,  whicli  led  to  a  tardy  convalescence.  The  recognition  of 
the  essentially  physiological  character  of  labor  has  resulted  in  more 
sound  views,  with  manifest  advantage  to  our  patients.  The  main 
facts  to  bear  in  mind  with  regard  to  the  puerperal  woman  are,  her 
nervous  susceptibility,  which  necessitates  quiet  and  absence  of  all 
excitement ;  the  importance  of  favoring  involution  by  prolonged 
rest;  and  the  risk  of  septiccemia,  which  calls  for  perfect  cleanliness 
and  attention  to  hygienic  precautions. 

The  Administration  of  Oj^iates  is  generally  Unadvisahle. — As  soon 
as  we  are  satisfied  that  the  uterus  is  perfectly  contracted,  and  that 
all  risk  of  hemorrhage  is  over,  the  patient  should  be  left  to  sleep. 
Many  jDractitioners  administer  an  opiate;  but,  as  a  matter  of  routine, 
this  is  certainly  not  good  practice,  since  it  checks  the  contractions  of 
the  uterus,  and  often  produces  unpleasant  efi'ects.  Still,  if  the  labor 
have  been  long  and  tedious,  and  the  patient  be  much  exhausted,  15 
or  20  drops  of  Battley's  solution  may  be  administered  with  advantage. 

Attention  to  the  State  of  the  Pulse,  Bladder,  and  Uterus. — Within  a 
few  hours  the  patient  should  be  seen,  and  at  the  first  visit  particular 
attention  should  be  paid  to  the  state  of  the  pulse,  the  uterus,  and 
the  bladder.  The  pulse  during  the  whole  period  of  convalescence 
should  be  carefully  watched,  and,  if  it  be  at  all  elevated,  the  tem- 


548  THE    PUERPERAL    STATE. 

perature  sliould  at  once  be  taken.  If  tlie  pulse  and  temperature 
remain  normal,  we  may  be  satisfied  tliat  tilings  are  going  on  well; 
but  if  the  one  be  quickened  and  the  other  elevated,  some  disturbance 
or  complication  may  be  apprehended.  The  abdomen  should  be  felt 
to  see  that  the  uterus  is  not  unduly  distended,  and  that  there  is  no 
tenderness.     After  the  first  day  or  two  this  is  no  longer  necessary. 

Treatment  of  Retention  of  Urine. — Sometimes  the  patient  cannot 
at  first  void  the  urine,  and  the  application  of  a  hot  sponge  over  the 
pubis  may  enable  her  to  do  so.  If  the  retention  of  urine  be  due  to 
temporary  paralysis  of  the  bladder,  three  or  four  20-minim  doses  of 
the  liquid  extract  of  ergot,  at  intervals  of  half  an  hour,  may  prove 
successful.  Many  hours  should  not  be  allowed  to  elapse  without  re- 
lieving the  patient  by  the  catheter,  since  prolonged  retention,  is  only 
likely  to  make  matters  worse.  Subsequently,  it  may  be  necessary 
to  empty  the  bladder  night  and  morning,  until  the  patient  regain  her 
power  over  it,  or  until  the  swelling  of  the  urethra  subsides,  and  this 
will  generally  be  the  case  in  a  few  days.  Occasionally  the  bladder 
becomes  largely  distended,  and  is  relieved  to  some  degree  by  drib- 
bling of  urine  from  the  urethra.  Such  a  state  of  things  may  deceive 
the  patient  and  nurse,  and  may  produce  serious  consequences  by 
causing  cystitis.  Attention  to  the  condition  of  the  abdomen  will 
prevent  the  practitioner  from  being  deceived,  for  in  addition  to  some 
constitutional  disturbance,  a  large,  tender,  and  fluctuating  swelling 
will  be  found  in  the  hypogastric  region,  distinct  from  the  uterus, 
which  it  displaces  to  one  or  other  side.  The  catheter  will  at  once 
prove  that  this  is  produced  by  distension  of  the  bladder. 

Treatment  of  Severe  After-jmins. — If  the  after-pains  be  very  severe, 
an  opiate  may  be  administered,  or,  if  the  lochia  bo  not  over-abun- 
dant, a  linseed-meal  poultice,  sprinkled  with  laudanum,  or  with  the 
chloroform  and  belladonna  liniment,  may  be  applied.  If  proper  care 
have  been  taken  to  induce  uterine  contraction,  they  will  seldom  be 
sufficiently  severe  to  require  treatment.  In  America,  quinine  in 
doses  of  10  grains  twice  daily,  has  been  strongly  recommended,  espe- 
cially when  opiates  fail,  and  when  the  pains  are  neuralgic  in  char- 
acter, and  I  have  found  this  remedy  answer  extremely  well.  The 
quinine  is  best  given  in  solution  with  10  or  15  minims  of  hydrobro- 
mic  acid,  which  materially  lessens  the  unpleasant  head  symptoms 
often  accompanying  the  administration  of  such  large  doses. 

Diet  and  Regimen. — The  diet  of  the  puerperal  patient  claims  care- 
ful attention,  the  more  so  as  old  prejudices  in  this  respect  are  as  jei 
far  from  exploded,  and  as  it  is  by  no  means  rare  to  find  mothers  and 
nurses  who  still  cling  tenaciously  to  the  idea  that  it  is  essential  to 
prescribe  a  low  regimen  for  many  days  after  labor.  The  erroneous- 
ness  of  this  plan  is  now  so  thoroughly  recognized,  that  it  is  hardly 
necessary  to  argue  the  point.  There  is,  however,  a  tendency  in  some 
to  err  in  the  opposite  direction,  which  leads  them  to  insist  on  the 
patient's  consuming  solid  food  too  soon  after  delivery,  before  she  has 
regained  her  appetite,  thereby  producing  nausea  and  intestinal  de- 
rangement. Our  best  guide  in  this  matter  is  the  feelings  of  the  pa- 
tient herself.     If,  as  is  often  the  case,  she  be  disinclined  to  eat,  there 


THE    PUERPERAL    STATE    AND    ITS    MANAGEMENT.  549 

is  no  reason  wliy  she  sliould  be  urged  to  do  so.  A  good  cup  of  beef- 
tea,  some  bread  and  milk,  or  an  egg  beat  up  with  mills:,  may  gener- 
ally be  given  with  advantage  shortly  after  delivery,  and  many  patients 
are  not  inclined  to  take  more  f(^r  the  first  day  or  so.  If  the  patient 
be  hungry  there  is  no  reason  why  she  should  not  have  some  more 
solid,  but  easily  digested  food,  such  as  wliite  fish,  chicken,  or  sweet- 
bread ;  and,  after  a  day  or  two,  she  may  resume  her  ordinary  diet, 
bearing  in  mind  that,  being  confined  to  bed,  she  cannot  Avith  advan- 
tage consume  the  same  amount  of  solid  food  as  when  she  is  up  and 
about.  Dr.  Oldham,  in  his  presidential  address  to  the  Obstetrical 
Society,^  has  some  apposite  remarks  on  this  point,  which  are  worthy 
of  quotation.  "A  puerperal  month  under  the  guidance  of  a  monthly 
nurse  is  easily  drawn  out,  and  it  is  well  if  a  love  of  the  comforts  of 
illness  and  the  persuasion  of  being  delicate,  which  are  the  infirmities 
of  many  women,  do  not  induce  a  feeble  life,  Avhich  long  survives 
after  the  occasion  of  it  is  forgotten.  I  know  no  reason  Avhy,  if  a 
woman  is  confined  early  in  the  morning,  she  should  not  have  her 
breakfast  of  tea  and  toast  at  nine,  her  luncheon  of  some  digestible 
meat  at  one,  her  cup  of  tea  at  five,  her  dinner  with  chicken  at  seven, 
and  her  tea  again  at  nine,  or  the  equivalent,  according  to  the  varia- 
tion of  her  habits  of  living."  [The  practice  in  general  in  the  United 
States  has  been  to  avoid  the  use  of  stimulating  food  for  two  or  three 
days  after  delivery,  on  the  same  principle  that  low  diet  is  used  in  the 
different  forms  of  abdominal  surgery.  Full  diet  and  animal  food  might 
possibly  answer  in  many  of  our  cases  without  risk  ;  and  beef  essence 
we  know  is  of  much  value  after  hemorrhage,  but  in  health}^  vigorous 
subjects  I  see  no  occasion  to  -ignore  the  teaching  of  the  past,  when 
based  upon  sound  reasoning.  I  believe  in  dieting  the  robust,  and 
feeding  up  the  delicate.  By  "  dieting"  I  do  not  mean  the  old  starvation 
system  ;  but  plain,  simple,  nutritious  food. — Ed.]  "  Of  course,  there 
is  the  common-sense  selection  of  articles  of  food,  ffuardinsi;  ao-ainst 
excess,  and  avoiding  stimailants.  But  gruel  and  slops,  and  all  inter- 
mediate feeding,  are  to  be  avoided."  Ko  one  who  has  seen  both 
methods  adopted  can  fail  to  have  been  struck  with  the  more  rapid 
and  satisfactory  convalescence  which  takes  place  when  the  patient's 
strength  is  not  weakened  by  an  unnecessarily  low  diet.  Stimulants, 
as  a  rule,  are  not  required ;  but,  if  the  patient  be  weakly  and  ex- 
hausted, or  if  she  be  accustomed  to  their  use,  there  can  be  no  reason- 
able objection  to  their  judicious  administration. 

Attention  to  Cleanliness^  etc. — Immediately  after  delivery  a  warm 
napkin  is  applied  to  the  vulva,  and,  after  the  patient  has  rested  a 
little,  the  nurse  removes  the  soiled  linen  from  the  bed,  and  washes 
the  external  genitals.  It  is  impossible  to  pay  too  much  attention 
during  the  subsequent  progress  of  the  case  to  the  maintenance  of 
perfect  cleanliness.  Perfectly  antiseptic  midwifery  is  no  doubt  an 
impossibility ;  but  a  near  approach  to  it  may  be  made,  and  the 
greater  the  care  taken,  the  more  certainly  will  the  safety  of  the 
patient  be  insured.     It  will  be  a  wise  precaution  to  advise  the  nurse 

'  Obstet.  Trans.,  vol.  vi. 


550  TUB    PUERPERAL    STATE. 

never  to  touch  the  genitals  for  the  first  few  days,  unless  her  hands 
have  boon  moistened  in  a  1  in  20  solution  of  carbohc  acid,  or  lubri- 
cated with  carbolized  oil.  The  linen  should  be  frequently  changed, 
and  all  dirty  linen  and  discharges  immediately  removed  from  the 
apartment.  The  vulva  should  be  washed  daily  with  Condy's  fluid 
and  water,  and  the  patient  will  derive  great  comfort  from  having,  the 
vagina  syringed  gently  out  once  a  day  with  the  same  solution.  The 
remarkable  diminution  of  mortality  which  has  followed  such  anti- 
septic precautions  in  certain  Lying-in  Hospitals  in  Germany,  well 
shows  the  importance  of  these  measures.  The  room  should  bo  kept 
tolerably  cool,  and  fresh  air  freely  admitted. 

Action  of  the  Bowels.- — It  is  customary,  on  the  morning  of  the 
second  or  third  daj^,  to  secure  an  action  of  the  bowels ;  and  there  is 
no  better  way  of  doing  this  than  by  a  large  enema  of  soap  and  water. 
If  the  patient  object  to  this,  and  the  bowels  have  not  acted,  some 
mild  aperient  may  be  administered,  such  as  a  small  dose  of  castor 
oil,  a  few  grains  of  colocynth.  and  henbane  pill,  or  the  popular  French 
aperieut,  the  "  Tamar  Indieu." 

Lactation. — The  management  of  suckling  and  of  the  breasts  forms 
an  important  part  of  the  duties  of  the  monthly  nurse,  which  the 
practitioner  should  himself  superintend.  This  will  be  more  conven- 
iently discussed  under  the  head  of  lactation. 

Importance  of  Prolonged  Best. — The  most  important  part  of  the 
management  of  the  puerperal  state  is  the  securing  to  the  patient  pro- 
longed rest  in  the  horizontal  position,  in  order  to  favor  proper  invo- 
lution of  the  uterus.  For  the  first  few  days  she  should  be  kept  as 
quiet  and  still  as  possible,  not  receiving  the  visits  of  any  but  her 
nearest  relatives,  thus  avoiding  all  chance  of  undue  excitement.  It 
is  customary  among  the  better  classes  for  the  patient  to  remain  in 
bed  for  eight  or  ten  days  ;  but,  provided  she  be  doing  well,  there  can 
be  no  objection  to  her  lying  on  the  outside  of  the  bed,  or  slipping  on 
to  a  sofa,  somewhat  sooner.  After  ten  days  or  a  fortnight  she  may 
be  permitted  to  sit  on  a  chair  for  a  little ;  but  I  am  convinced  that 
the  longer  she  can  be  persuaded  to  retain  the  recumbent  position, 
the  more  complete  and  satisfactory  will  be  the  progress  of  involution, 
and  she  should  not  be  allowed  to  walk  about  until  the  third  week, 
about  which  time  she  may  also  be  permitted  to  take  a  drive.  If  it 
be  borne  in  mind  that  it  takes  from  six  weeks  to  two  months  for  the 
uterus  to  regain  its  natural  size,  the  reason  for  prolonged  rest  will  be 
obvious.  The  judicious  practitioner,  however,  while  insisting  on  this 
point,  will  take  measures  at  the  same  time,  not  to  allow  the  patient 
to  lapse  into  the  habit  of  an  invalid,  or  to  give  the  necessary  rest 
the  semblance  of  disease. 

Subsequent  Treatment. — -ToAvards  the  termination  of  the  puerperal 
month  some  slight  tonic,  such  as  small  doses  of  quinine  with  phos- 
phoric acid,  may  be  often  given  with  advantage,  especially  if  conva- 
lescence be  tardy.  Nothing  is  so  beneficial  in  restoring  the  patient 
to  her  usual  health,  as  change  of  air,  and  in  the  upper  classes  a  short 
visit  to  the  seaside  may  generally  be  recommended,  with  the  certainty 
of  much  benefit. 


MANAGEMENT    OF    THE    INFANT,    LACTATION,    ETC.  551 


CHAPTEE  II. 

MANAGEMENT    OF    TUE    INFANT,  LACTATION,  ETC. 

Commencement  of  Respiration. — Almost  immediately  after  its  ex- 
pulsion, a  healthy  child  cries  aloud,  thereby  showing  that  respiration 
is  established,  and  this  may  be  taken  as  a  signal  of  its  safety.  The 
first  respiratory  movements  are  excited,  partially  by  reflex  action 
resulting  from  the  contact  of  the  cold  external  air  on  the  cutaneous 
nerves,  and  partly  by  the  direct  irritation  of  the  medulla  oblongata, 
in  consequence  of  the  circulation  through  it  of  blood  no  longer  oxy- 
genated in  the  placenta. 

Ai^iparent  Death  of  the  New-horn  Child. — ISTot  infrequently  the  child 
is  boi'n  in  an  apparently  lifeless  state.  This  is  especially  likely  to 
be  the  case  when  the  second  stage  of  labor  has  been  unduly  pro- 
longed, so  that  the  head  has  been  subjected  to  long-continued  pres- 
sure. The  utero- placental  circulation  is  also  apt  to  be  injuriously 
interfered  with  before  the  birth  of  the  child  when  a  tardy  labor  has 
produced  tonic  contraction  of  the  uterus,  and  consequent  closure  of 
the  uterine  sinuses ;  or,  more  rarely,  from  such  causes  as  the  injudi- 
cious administration  of  ergot,  premature  separation  of  the  placenta, 
or  compression  of  the  umbilical  cord.  In  any  of  these  cases  it  is 
probable  that  the  arrest  of  the  utero-placental  circulation  induces 
attempts  at  inspiration,  which  are  necessarily  fruitless,  since  air  cannot 
reach  the  lungs,  and  the  foetus  may  die  asphyxiated  ;  the  existence 
of  the  respiratory  movement  being  proved  on  post-mortem  examina- 
tion by  the  presence  in  the  lungs  of  liquor  amnii,  mucus,  and  meco- 
nium, and  by  the  extravasation  of  blood  from  the  rupture  of  their 
engorged  vessels. 

Appearance  of  the  Child  in  such  Cases. — In  most  cases,  when  the 
child  is  born  in  a  state  of  apparent  asphyxia,  its  face  is  swollen  and 
of  a  dark  livid  color.  It  not  infrequently  makes  one  or  two  feeble 
and  gasping  efforts  at  respiration,  without  any  definite  cry ;  on  aus- 
cultation the  heart  may  be  heard  to  beat  weakly  and  slowly.  Under 
such  circumstances  there  is  a  fair  hope  of  its  recovery.  In  other 
cases  the  child,  instead  of  being  turgid  and  livid  in  the  face,  is  pale, 
with  flaccid  limbs,  and  no  apj^reciable  cardiac  action,  then  the  prog- 
nosis is  much  more  unfavorable. 

Treatment  of  Api^arent  Death. — ISTo  time  should  be  lost  in  endeavor- 
ing to  excite  respiration,  and,  at  first,  this  must  be  done  by  applying 
suitable  stimulants  to  the  cutaneous  nerves,  in  the  hope  of  exciting 
reflex  action.  The  cord  should  be  at  once  tied,  and  the  child  re- 
moved from  the  mother  ;  for  the  final  uterine  contractions  have  so 
completely  arrested  the  utero-placental  circulation,  as  to  render  it  no 


552  THE    PUERPERAL    STATE. 

longer  of  any  value.  If  the  face  be  very  livid,  a  fevi  drops  of  blood 
may  with  advantage  be  allowed  to  flow  from  the  cord  before  it  is 
tied,  with  the  view  of  relieving  the  embarrassed  circulation.  Yery 
often  some  slight  stimulus,  such  as  one  or  two  sharp  slaps  on  the 
thorax,  or  rapidly  rubbing  the  body  with  brandy  poured  into  the 
palms  of  the  hands,  will  sufiice  to  induce  respiration.  Failing  this, 
nothing  acts  so  well  as  the  sudden  and  instantaneous  application  of 
heat  and  cold.  For  this  purpose  extremely  hot  water  is  placed  in 
one  basin,  and  quite  cold  water  in  another.  Taking  the  child  by 
the  shoulders  and  legs,  it  should  be  dipped  for  a  single  moment  into 
the  hot  water,  and  then  into  the  cold ;  and  these  alternate  applica- 
tions may  be  repeated  once  or  twice,  as  occasion  requires.  The 
effect  of  this  measure  is  often  very  marked,  and  I  have  frequently 
seen  it  succeed  when  prolonged  efforts  at  artificial  respiration  had 
been  made  in  vain. 

Artificial  JResjnration.' — If  these  means  fail,  an  endeavor  must  be 
at  once  made  to  carry  on  respiration  artificially.  The  Sylvester 
method  is,  on  the  whole,  that  which  is  most  easily  applied,  and,  on 
account  of  the  compressibility  of  the  thorax,  it  is  peculiarly  suitable 
for  infants.  The  child  being  laid  on  its  back,  with  the  shoulders 
slightly  elevated,  the  elbows  are  grasped  by  the  operator,  and  alter- 
nately raised  above  the  head,  and  slowly  depressed  against  the  sides 
of  the  thorax,  so  as  to  produce  the  efiect  of  inspiration  and  expira- 
tion. If  this  do  not  succeed,  the  Marshall  Hall  method  may  be  sub- 
stituted ;  and  one  or  more  of  the  plans  of  exciting  reflex  action 
through  the  cutaneous  nerves  may  be  alternated  with  it. 

Insiififlation  of  the  Linvjs. — Other  means  of  exciting  respiration  have 
been  recommended.  One  of  them,  much  used  abroad,  is  the  artificial 
insufflation  of  the  lungs  by  means  of  a  flexible  catheter  guided  into 
the  glottis.  It  is  not  difficult  to  pass  the  end  of  a  catheter  into  the 
glottis,  using  the  little  finger  as  a  guide  ;  and  once  in  position,  it  may 
be  used  to  blow  air  gently  into  the  lungs,  which  is  expelled  by  com- 
pression on  the  thorax,  the  insufflation  being  repeated  at  short  inter- 
vals of  about  ten  seconds.  One  advantage  of  this  plan  is,  that  it 
allows  the  liquor  arnnii  and  other  fluids,  which  may  have  been 
drawn  into  the  lungs  in  the  premature  efforts  at  respiration  before 
birth,  to  be  sucked  up  into  the  catheter,  and  so  removed  from  the 
lungs.  The  same  eiTect  may  be  produced,  but  less  perfectly,  by 
placing  the  hand  over  the  nostrils  of  the  child,  blowing  into  its 
mouth,  and  immediately  afterwards  compressing  the  thorax.^  One 
of  these  methods  should  certainly  be  tried,  if  all  other  means  have 
failed.  Faradization  along  the  course  of  the  phrenic  nerves  is  a 
promising  means  of  inducing  respiration,  which  should  be  used  if 
the  proper  apparatus  can  be  procured.  Encouragement  to  persevere 
in  our  endeavors  to  resuscitate  the  child  may  be  derived  from  the 
numerous   authenticated    instances  of  success  after  the  lapse  of  a 

['  When  this  is  done  the  oesophagus  must  be  closed  by  i^lacing  the  thumb  and 
fingers  on  opposite  sides  of  the  larynx,  and  pressing  it  backward,  just  before  blowing 
in  the  mouth.  When  this  is  accomplished  so  as  to  fill  the  lungs,  the  thorax  should 
be  pressed,  and  the  inflation  repeated. — Ed. J 


MANAGEMENT    OF    THE    INFANT,    LACTATION,    ETC.  55d 

considerable  time,  even  of  an  Iiour  or  more.    As  long  as  the  cardiac 
pulsations  continue,  however  feebly,  there  is  no  reason  to  despair. 

Waslung  and  Uressiwj  of  the  Cltild. — When  the  child  cries  lustily 
from  the  first,  it  is  customary  for  the  nurse  to  wash  and  dress  it  as 
soon  as  her  immediate  attendance  on  the  mother  is  no  longer  required. 
For  this  purpose  it  is  placed  in  a  bath  of  Avarm  water,  and  carefully 
soaped  and  sponged  from  head  to  foot.  With  the  view  of  facilitating 
the  removal  of  the  unctuous  material  with  which  it  is  covered,  it  is 
usual  to  anoint  it  with  cold  cream  or  olive-oil,  w^hich  is  washed  off 
in  the  bath.  Nurses  are  apt  to  use  undue  roughness  in  endeavoring 
to  remove  every  particle  of  the  vernix  caseosa,  small  portions  of 
which  are  often  firmly  adherent.  This  mistake  should  be  avoided,  as 
these  particles  will  soon  dry  up  and  become  spontaneous!}^  detached. 
The  cord  is  generally  wrapped  in  a  small  piece  of  charred  linen, 
which  is  supposed  to  have  some  slight  antiseptic  propert}",  and  this 
is  renewed  from  day  to  day  until  the  cord  has  withered  and  separated. 
This  generally  occurs  within  a  week  ;  and  a  small  pad  of  soft  linen  is 
then  placed  over  the  umbilicus,  and  supported  by  a  flannel  belly- 
band,  placed  round  the  abdomen,  which  should  not  be  too  tight,  for 
fear  of  embarrassing  the  respiration.  By  this  means  the  tendency 
to  umbilical  hernia  is  prevented.  [As  the  vernix  caseosa  is  readily 
miscible  with  pure  lard,  and  can  be  easily  removed  by  its  means,  it 
has  become  the  practice  Avith  many  obstetricians  in  the  United  States 
to  order  the  infant  to  be  well  anointed,  and  then  wiped  from  head  to 
foot  with  soft  rags,  until  all  the  vernix  disappears  and  the  skin 
retains  a  slight  oily  trace,  not  enough  to  soil  the  clothing.  By  this 
means  water  is  avoided,  and  with  it  much  of  the  risk  of  taking  cold; 
and  the  skin  is  left  less  sensitive  after  the  sudden  change  which  it  is 
made  to  endure  at  birth  than  when  subjected  to  hot  water  and  soap. 
In  the  hot  months  water  is  preferable  at  the  first  dressing. — Ed.] 

Clothing,  etc. — The  clothing  of  the  infant  varies  according  to  fashion 
and  the  circumstances  of  the  parents.  The  important  points  to  bear 
in  mind  are  that  it  should  be  warm  (since  newly-born  children  are 
extremely  susceptible  to  cold),  and  at  the  same  time  light  and  sufii- 
ciently  loose  to  allow  free  play  to  the  limbs  and  thorax.  All  tight 
bandaging  and  swaddling,  such  as  is  so  common  in  some  parts  of  the 
Continent,  should  be  avoided,  and  the  clothes  should  be  fastened  by 
strings  or  by  sewing,  and  no  pins  used.  At  the  present  day  it  is 
customary  not  to  use  caps,  so  that  the  head  may  be  kept  cool.  The 
utmost  possible  attention  should  be  paid  to  cleanliness,  and  the  child 
should  be  regularly  bathed  in  tepid  water,  at  first  once  daily,  and 
after  the  first  few  Aveeks  both  night  and  morning.  After  drying, 
the  flexures  of  the  thighs  and  arms,  and  the  nates,  should  be  dusted 
Avith  violet  poAvder  or  Fuller's  earth,  to  prevent  chafing  of  the  skin. 
The  excrements  should  be  received  in  napkins  wrapped  round  the 
hips,  and  great  care  is  required  to  change  the  napkins  as  often  as 
they  are  Avet  or  soiled,  otherwise  troublesome  irritation  will  arise. 
A  neglect  of  this  ]3rccaution,  and  the  washing  of  the  napkins  Avith 
coarse  soap  or  soda,  are  among  the  principal  causes  of  the  eruptions 
and  excoriations  so  common  in  badly  cared  for  children.  When 
36 


554  THE    PUERPERAL    STATE. 

washed  and  dressed  the  child  may  be  placed  in  its  cradle,  and  covered 
with  soft  blankets  or  an  eider-down  quilt. 

AjJj^lication  of  the  Child  to  the  Breast. — As  soon  as  the  mother  has 
rested  a  little,  it  is  advisable  to  place  the  child  to  the  breast.  This 
is  useful  to  the  mother  bj  favoring  uterine  contraction.  Even  now 
there  is  in  the  breasts  a  variable  quantity  of  the  peculiar  fluid  known 
as  colostrum.  This  is  a  viscid  yellowish  secretion,  different  in  appear- 
ance from  the  thin  bluish  milk  which  is  subsequently  formed.  Ex- 
amined under  the  microscope  it  is  found  to  contain  some  milk 
globules,  a  number  of  large  granular  and  small  fat  corpuscles.  It 
has  a  purgative  property,  and  soon  produces  with  less  irritation 
than  any  of  the  laxatives  so  generally  used,  a  discharge  of  the  meco- 
nium with  which  the  bowels  are  loaded.  Hence  the  accoucheur 
should  prohibit  the  common  practice  of  administering  castor  oil,  or 
other  aperient,  within  the  first  few  days  after  birth,  although  there 
can  be  no  objection  to  it,  in  special  cases,  if  the  bowels  appear  to  act 
inefficiently  and  with  difficulty. 

Over-frequent  Suchling  should  he  Avoided. — For  the  first  few  days, 
and  until  the  secretion  of  milk  is  thoroughly  established,  the  child 
should  be  put  to  the  breast  at  long  intervals  only.  Constant  attempts 
at  suckling  an  empty  breast  lead  to  nothing  but  disappointment,  both 
to  the  mother  and  child,  and,  by  unduly  irritating  the  mammae,  some- 
times to  positive  harm.  Therefore,  for  the  first  day  or  two,  it  is 
sufficient  if  the  child  be  applied  to  the  breast  twice,  or  at  most  three 
times,  in  the  twenty-four  hours.  Nor  is  it  necessary  to  be  apprehen- 
sive as  many  mothers  naturally  are,  that  the  child  will  suffer  from 
want  of  food.  A  few  spoonfuls  of  milk  and  water  being  given  from 
time  to  time,  the  child  may  generally  wait  without  injury  until  the 
milk  is  secreted.  This  is  generally  about  the  third  day,  when  the 
secretion  is  found  to  be  a  whitish  fluid,  more  watery  in  appearance 
than  cow's  milk,  and  showing  under  the  microscope  an  abundance 
of  minute  spherical  globules,  refracting  light  strongly,  which  are 
abundant  in  proportion  to  the  quality  of  the  milk.  A  certain  number 
of  granular  corpuscles  may  also  be  observed  shortly  after  the  birth 
of  the  child,  but,  after  the  first  month,  these  should  have  almost 
altogether  disappeared.  The  reaction  of  human  milk  is  decidedly 
alkaline,  and  the  taste  much  sweeter  than  that  of  cow's  milk. 

Importance  of  Niirsing  when  Practicahle. — The  importance  to  the 
mother  of  nursing  her  own  child,  whenever  her  health  permits,  on 
account  of  the  favorable  influence  of  lactation  in  promoting  a  proper 
involution  of  the  uterus,  has  already  been  insisted  on.  Unless  there 
be  some  positive  contra-indication,  such  as  a  marked  strumous 
cachexia,  an  hereditary  phthisical  tendency,  or  great  general  debil- 
ity, it  is  the  duty  of  the  accoucheur  to  urge  the  mother  to  attempt 
lactation,  even  if  it  be  not  carried  on  more  than  a  month  or  two.  It 
is,  however,  the  fact  that  in  the  upper  classes  of  society  a  large 
number  of  patients  are  unable  to  nurse,  even  though  Avilling  and 
anxious  to  do  so.  In  some  there  is  hardly  any  lacteal  secretion  at 
all,  in  others  there  is  at  first  an  over-abundance  of  watery  and  innu- 
tritions milk,  which  floods  the  breasts,  and  soon  dies  away  altogether. 


MANAGEMENT    OP    THE    INFANT,    LACTATION,    ETC.  555 

Whe7i  the  Motlier  cannot  Nurse  a  Wet  Nurse  should  he  Procured. — 
Whenever  the  mother  cannot  or  will  not  nurse,  the  question  will 
arise  as  to  the  method  of  bringing  up  the  child.  From  many  causes 
there  is  an  increasing  tendency  to  resort  to  bottle-feeding,  instead  of 
procurino"  the  services  of  a  wet  nurse,  even  when  the  question  of 
expense  does  not  come  into  consideration.  No  long  experience  is 
required  to  prove  that  hand  feeding  is  a  bad  and  imperfect  substitute 
for  nature's  mode,  and  one  which  the  practitioner  should  discourage 
whenever  it  lies  in  his  power  to  do  so.  It  is  true  that,  in  many 
cases,  bottle-fed  children  do  well ;  but  there  is  good  reason  to  believe 
that,  even  when  apparently  most  successful,  the  children  are  not  so 
strong  in  after-life  as  they  would  have  been  had  they  been  brought 
up  at  the  breast.  When,  in  addition,  it  is  borne  in  mind  how  much 
of  the  success  of  hand-feeding  depends  on  intelligent  care  on  the 
part  of  the  nurse,  what  evils  are  apt  to  accrue  from  injurious  selec- 
tion of  food,  and  from  ignorance  of  the  commonest  laws  of  dietetics, 
there  is  abundant  reason  for  urging  the  substitution  of  a  wet  nurse, 
whenever  the  mother  is  unable  to  undertake  the  suckling  of  her 
child.  It  must  be  admitted  that  good  hand-feedins:  is  better  than 
bad  wet-nursing,  and  the  success  of  the  latter  hinges  on  the  proper 
selection  of  a  wet  nurse.  As  this  falls  within  the  duties  of  the  prac- 
titioner, it  will  be  well  to  point  out  the  qualities  which  should  be 
sought  for  in  a  wet  nurse,  before  proceeding  to  discuss  the  mode  of 
rearing  the  child  at  the  breast. 

Selection  of  a  Wet  Narse. — In  selecting  a  wet  nurse  we  should  en- 
deavor to  choose  a  strong,  healthy  woman,  who  should  not  be  over 
30,  or  35  years  of  age  at  the  outside,  since  the  quality  of  the  milk 
deteriorates  in  women  who  are  more  advanced  in  life.  For  a  similar 
reason  a  very  young  woman  of  16  or  17  should  be  rejected.  It  is 
needless  to  say  that  care  must  be  taken  to  ascertain  the  absence  of 
all  traces  of  constitutional  disease,  especially  marks  of  scrofula,  or 
enlarged  cervical  or  inguinal  glands,  which  may  possibly  be  due  to 
antecedent  syphilitic  taint.  If  the  nurse  be  of  good  muscular  de- 
velopment, healthy-looking  with  a  clear  complexion,  and  sound 
teeth  (indicating  a  generally  good  state  of  health),  the  color  of  the 
hair  and  eyes  are  of  secondary  importance.  It  is  commonly  stated 
that  brunettes  make  better  nurses  than  blondes,  but  this  is  by  no 
means  necessarily  the  case ;  and,  provided  all  the  other  points  be  favor- 
able, fairness  of  skin  and  hair  need  be  no  bar  to  the  selection  of  a 
nurse.  The  breasts  should  be  pear-shaped,  rather  firm,  as  indicating 
an  abundance  of  gland-tissue,  and  with  the  superficial  veins  well 
marked.  Large,  flabby  breasts  owe  much  of  their  size  to  an  undue 
deposit  of  fat,  and  are  generally  unfavorable.  The  nipple  should  be 
prominent,  not  too  large,  and  free  from  cracks  and  erosions,  which, 
if  existing,  might  lead  to  subsequent  difficulties  in  nursing.  On 
pressing  the  breast  the  milk  should  flow  from  it  easily  in  a  number 
of  small  jets,  and  some  of  it  should  be  preserved  for  examination. 
It  should  be  of  a  bluish -white  color,  and  when  placed  under  the 
microscope,  the  field  should  be  covered  with  an  abundance  of  milk 
corpuscles,  and  the  large  granular  corpuscles  of  the  colostrum  should 


556  THE    PUERPERAL    STATE. 

have  entirely  disappeared.  If  the  latter  be  observed  in  any  quantity 
in  a  woman  who  has  been  confined  five  or  six  weeks,  the  inference 
is  that  the  milk  is  inferior  in  quahty.  It  is  not  often  that  the  prac- 
titioner has  an  opportunity  of  inquiring  into  the  moral  qualities  of 
the  nurse,  although  much  valuable  intbrmation  might  be  derived 
from  a  knowledge  of  her  previous  character.  An  irascible,  excit- 
able, or  highly  nervous  woman  will  certainly  make  a  bad  nurse,  and 
the  most  trivial  causes  might  afterwards  interfere  with  the  quality 
of  her  milk.  Particular  attention  should  be  paid  to  the  nurse's  own 
child,  since  its  condition  affords  the  best  criterion  of  the  quality  of 
her  milk.  It  should  be  plump,  well  nourished,  and  free  from  all 
blemishes.  If  it  be  at  all  thin  and  wizened,  especially  if  there  be 
any  'snuffling  at  the  nose,  or  should  any  eruption  exist  affording  the 
slightest  suspicion  of  a  syphilitic  taint,  the  nurse  should  be  unhesi- 
tatingly rejected. 

Mcmagement  of  SuchUng. — The  management  of  suckling  is  much 
the  same  whether  the  child  is  nursed  by  the  mother  or  by  a  wet 
nurse.  As  soon  as  the  supply  of  milk  is  sufficiently  established, 
the  child  must  be  put  to  the  breast  at  short  intervals,  at  first  of  about 
two  hours,  and,  in  about  a  month  or  six  weeks,  of  three  hours.  From 
the  first  few  days  it  is  a  matter  of  the  greatest  importance,  both 
to  the  mother  and  child,  to  acquire  regular  habits  in  this  respect. 
If  the  mother  get  into  the  way  of  allowing  the  infant  to  take  the 
breast  whenever  it  cries,  as  a  means  of  keeping  it  quiet,  her  own 
health  must  soon  suffer,  to  say  nothing  of  the  discomfort  of  being 
incessantly  tied  to  the  child's  side :  while  the  child  itself  has  not 
suflEicient  rest  to  digest  its  food,  and,  very  shortly,  diarrhoea,  or  other 
symptoms  of  dyspepsia,  are  pretty  sure  to  follow.  After  a  mouth  or 
two  the  infant  should  be  trained  to  require  the  breast  less  often  at 
night,  so  as  to  enable  the  mother  to  have  an  undisturbed  sleep  of  six 
or  seven  hours.  For  this  purpose  she  should  arrange  the  times  of 
nursing  so  as  to  give  the  breast  just  before  she  goes  to  bed,  and  not 
again  until  the  early  morning.  If  the  child  should  require  food  m 
the  interval,  a  little  milk  and  water,  from  the  bottle,  may  be  advan- 
tageously given. 

''Diet  of  Nursing  Women. — The  diet  of  the  nursing  woman  should  be 
arranged  on  ordinary  principles  of  hygiene.  It  should  be  abundant, 
simple,  and  nutritious,  and  all  rich  and  stimulating  articles  of  food 
should  be  avoided.  A  common  error  in  the  diet  of  wet  nurses  is 
over-feeding,  which  constantly  leads  to  deterioration  of  the  milk. 
Many  of  these  women,  before  entering  on  their  functions,  have  been 
living  on  the  simplest  and  even  sparest  diet,  and  not  uncommonly, 
in  the  better  class  of  houses,  they  are  suddenly  given  heavy  meat 
meals  three  and  even  four  times  a  day,  and  often  three  or  four  glasses 
of  stout.  It  is  hardly  a  matter  of  astonishment  that,  under  such  cir- 
cumstances, their  milk  should  be  found  to  disagree.  For  a  nursing 
woman  in  good  health  two  good  meat  meals  a  day,  with  two  glasses 
of  beer  or  porter,  and  as  much  milk  and  bread  and  butter  as  she 
likes  to  take  in  the  interval,  should  be  amply  sufhcient.  Plenty  of 
moderate  exercise  should  be  taken,  and  the  more  nurse  and  child  are 


MANAGEMENT    OP    THE    INFANT,    LACTATION,    ETC.  557 

out  in  the  open  air,  provided  the  weatlier  be  reasonably  fine,  the 
better  it  is  for  both. 

[As  it  is  not  the  custom  of  American  wet  nurses  to  drink  beer  or 
stout,  this  part  of  their  diet  is  u.ndesirable.  A  healthy  woman  should 
have  milk  enough  from  her  ordinary  diet,  which  should  be  largely 
farinaceous.  If  milk  agrees  with  her,  it  is  far  better  than  malt 
drinks  in  the  production  of  a  lacteal  supply. — Ed.] 

Signs  of  Successful  Lactation. — Carried  on  methodically  in  this 
manner,  wet  nursing  should  give  but  little  trouble.  In  the  intervals 
between  its  meals  the  child  sleeps  most  of  its  time,  and  wakes  with 
regularity  to  feed;  but  if  the  child  be  wakeful  and  I'cstless,  cry  after 
feeding,  have  disordered  bowels,  and,  above  all,  if  it  do  not  gain, 
week  by  week,  in  weight  (a  point  which  should  be,  from  time  to 
time,  ascertained  by  the  scales),  we  may  conclude  that  there  is  either 
some  grave  defect  in  the  management  of  suckling,  or  that  the  milk 
is  not  agreeing.  Should  this  unsatisfactory  progress  continue,  in  spite 
of  our  endeavors  to  remedy  it,  there  is  no  resource  left  but  the  alter- 
ation of  the  diet,  either  by  changing  the  nurse,  or  by  bringing  up 
the  child  by  hand.  The  former  should  be  preferred  whenever  it  is 
practicable,  and,  in  the  upper  ranks  of  life,  it  is  by  no  means  rare  to 
have  to  change  the  wet  nurse  two  or  three  times,  before  one  is  met 
with  whose  milk  agrees  perfectly.  If  the  child  have  reached  six  or 
seven  months  of  age,  it  may  be  preferable  to  wean  it  altogether, 
especially  if  the  mother  have  nursed  it,  as  hand-feeding  is  much 
less  objectionable  if  the  infant  have  had  the  breast  for  even  a  few 
months. 

Period  of  Weaning. — As  a  rule,  Aveaning  should  not  be  attempted 
until  dentition  is  fairly  established,  that  being  the  sign  that  nature 
has  prepared  the  child  for  an  alteration  of  food;  and  it  is  better  that 
the  main  portion  of  the  diet  should  be  breast  milk  until  at  least  six 
or  seven  teeth  have  appeared.  This  is  a  safer  guide  than  anj^  arbi- 
trary rule  taken  from  the  age  of  the  child,  since  the  commencement 
of  dentition  varies  much  in  different  cases.  About  the  sixth  or 
seventh  month  it  is  a  good  plan  to  commence  the  use  of  some  suita- 
ble artificial  food  once  a  day,  so  as  to  relieve  the  strain  on  the  mother 
or  nurse,  and  prepare  the  child  for  weaning,  Avhich  should  always  be 
a  very  gradual  process.  In  this  way  a  meal  of  rusks,  of  the  entire 
wheat  flour,  or  of  beef-  or  chicken-tea,  with  bread  crumb  in  it,  maj 
be  given  with  advantage;  and,  as  the  period  for  weaning  arrives,  a 
second  meal  may  be  added,  and  so  eventually  the  child  may  be  weaned 
without  distress  to  itself,  or  trouble  to  the  nurse. 

The  Disorders  of  Lactation. — The  disorders  of  lactation  are  nume- 
rous, and,  as  they  frequently  come  under  the  notice  of  the  practitioner, 
it  is  necessary  to  allude  to  some  of  the  most  common  and  important. 

Means  of  Arresting  the  Secretion  of  Milk.- — -The  advice  of  the  accou- 
cheur is  often  required  in  cases  in  which  it  has  been  determined  that 
the  patient  is  not  to  nurse,  when  we  desire  to  get  rid  of  the  milk  as 
soon  as  possible,  or  when,  at  the  time  of  weaning,  the  same  object  is 
sought.  The  extreme  heat  and  distension  of  the  breasts,  in  the  former 
class  of  cases,  often  give  rise  to  much  distress.     A  smart  saline  ape- 


558  THE    PUERPERAL    STATE. 

rient  will  aid  in  removing  the  milk,  and  for  this  purpose  a  double 
Seidlitz  powder,  or  frequent  small  doses  of  sulphate  of  magnesia,  act 
well;  while,  at  the  same  time,  the  patient  should  be  advised  to  take 
as  small  a  quantity  of  fluid  as  possible.  Iodide  of  potassium  in  large 
doses,  of  20  or  25  grains,  repeated  twice  or  thrice,  has  a  remarkable 
effect  in  arresting  the  secretion  of  milk.  This  observation  was  first 
empirically  made  by  observing  that  the  secretion  of  milk  was  arrested 
when  this  drug  was  administered  for  some  other  cause,  and  I  have 
frequently  found  it  answer  remarkably  well.  The  distension  of  the 
breasts  is  best  relieved  by  covering  them  with  a  layer  of  lint  or  cotton 
wool,  soaked  in  a  spirit  lotion,  or  eau  de  cologne  and  water,  over 
which  oiled  silk  is  placed,  and  by  directing  the  nurse  to  rub  them 
gently  with  warm  oil,  whenever  they  get  hard  and  lumpy.  Breast- 
pumps  and  similar  contrivances  only  irritate  the  breasts,  and  do  more 
harm  than  good.  The  local  application  of  belladonna  has  been  strongly 
recommended  as  a  means  for  preventing  lacteal  secretion.  As  usually 
applied,  in  the  form  of  belladonna  plaster,  it  is  likely  to  prove 
liurtful,  since  the  breast  often  enlarges  after  the  plasters  are  applied, 
and  the  pressure  of  the  unyielding  leather  on  which  they  are  spread 
produces  intense  suffering.  A  better  way  of  using  it  is  by  rubbing 
down  a  drachm  of  the  extract  of  belladonna  with  an  ounce  of  glyce- 
rine, and  applying  this  on  lint.  In  some  cases  it  answers  extremely 
well ;  but  it  is  very  uncertain  in  its  action,  and  frequently  is  quite 
useless. 

Defective  Secretion  of  Milk. — A  deficiency  of  milk  in  nursing 
mothers  is  a  Yorj  common  course  of  difficult}^.  In  a  wet  nurse  this 
drawback  is,  of  course,  an  indication  for  changing  the  nurse  ;  but  to 
the  mother  the  importance  of  nursing  is  so  great,  that  an  endeavor 
must  be  made  either  to  increase  the  flow  of  milk,  or  to  supplement 
it  by  other  food.  Unfortunately,  little  reliance  can  be  placed  on  any 
of  the  so-called  galactagogues.  The  only  one  which  in  recent  times 
has  attracted  attention  is  the  leaves  of  the  castor-oil  plant,  which, 
made  into  poultices  and  applied  to  the  breast,  are  said  to  have  a 
beneficial  effect  in  increasing  the  flow  of  milk.  More  reliance  must 
be  placed  in  a  sufficiency  of  nutritious  food,  especially  such  as  con- 
tains phosphatic  elements  ;  stewed  eels,  oj'-stzrs,  and  other  kinds  of 
shellfish,  and  the  Eevalenta  Arabica,  are  recommended  by  Dr.  Eouth, 
who  has  paid  some  attention  to  this  point,^  as  peculiarly  appropriate. 
If  the  amount  of  milk  be  decidedly  deficient,  the  child  should  be  less 
often  applied  to  the  breast,  so  as  to  allow  milk  to  collect,  and  prop- 
erly prepared  cow's  milk  from  a  bottle  should  be  given  alternately 
with  the  breast.  This  mixed  diet  generally  answers  well,  and  is  far 
preferable  to  pure  hand -feeding. 

[In  the  year  1870,^  I  prepared  an  article  showing  by  three  typical 
cases  the  value  of  milk  as  a  diet  for  certain  delicate  mothers,  who 
under  their  ordinary  food,  invariably  fail  to  be  able  to  nurse  longer 
than  a  few  weeks  or  months  after  parturition.     This  j^aper  was  pub- 

J  Routh  on  Infant-feeding. 
[2  Am.  Jonr.  Obstet.  Feb.  1870,  p.  675.] 


MANAGEMENT    OF    THE    INFANT,    LACTATION,    ETC.  659 

lished  by  various  periodicals  during  two  years,  and  the  plan  has 
been  brought  largely  into  use,  as  the  diet  is  capable  of  making  a 
good  nurse  out  of  a  mother,  who  but  for  it  would  make  a  complete 
failure,  and  of  fattening  her  up  during  the  time  that  she  is  secreting 
milk  in  abundance.  When  a  delicate  mother  of  86  pounds  weight, 
after  failing  in  a  month  with  each  of  three  infants,  is  enabled  by  it 
to  nurse  a  child  18  months,  and  gain  at  the  same  time  19  pounds, 
the  diet  must  be  an  efi'ective  one. — Ed.] 

Depressed  Nip-pies. — A  not  uncommon  source  of  difficulty  is  a  de- 
pressed condition  of  the  nipples  which  is  generally  produced  by  the 
constant  pressure  of  the  stays.  The  result  is,  that  the  child,  unable 
to  grasp  the  nipple,  and  wearied  with  ineffectual  efforts,  may  at  last 
refuse  the  breast  altogether.  An  endeavor  should  be  made  to  elon- 
gate the  nipple  before  putting  it  into  the  child's  mouth,  either  by  the 
fingers,  or  by  some  form  of  breast- pump,  which  here  finds  a  useful 
indication.  In  the  worst  class  of  cases,  when  the  nipple  is  perma- 
nently depressed,  it  may  be  necessary  to  let  the  child  suck  through 
a  glass  nipple  shield,  to  which  is  attached  an  India-rubber  tube, 
similar  to  that  of  a  sucking-bottle ;  that  it  is  generally  well  able 
to  do. 

[In  some  instances  this  anatomical  defect  appears  to  be  bej^ond 
remedy,  unless  a  recently  proposed  surgical  operation  can  be  made 
effective.  I  have  tried  to  prepare  primipara3  for  several  months  be- 
fore labor,  and  then  failed  as  soon  as  the  breasts  filled  with  milk. 
In  some  cases  there  is  absolutely  no  nipple,  and  as  a  shield  is  of  no 
value  in  protection,  the  escaping  milk  produces  an  eczema  over  the 
waist  and  upper  part  of  the  abdomen.  This  condition  I  have  seen 
associated  with  a  most  obstinate  galactorrhoea  lasting  several  months. 
—Ed.] 

Fissures  and  excoriations  of  the  nijoples  are  common  causes  of  suf- 
fering, in  some  cases  leading  to  mammary  abscess.  Whenever  the 
practitioner  has  the  opportunity,  he  should  advise  his  patient  to 
prepare  the  nipple  for  nursing  in  the  latter  months  of  pregnancy ; 
and  this  may  best  be  done  by  daily  bathing  it  with  a  spirituous  or 
astringent  lotion,  such  as  eau  de  cologne  and  water,  or  a  weak  solu- 
tion of  tannin.  After  nursing  has  begun,  great  care  should  be  taken 
to  wash  and  dry  the  nipple  after  the  child  has  been  applied  to  it,  and, 
as  long  as  the  mother  is  in  the  recumbent  position,  she  may,  if  the 
nipples  be  at  all  tender,  use  zinc  nipple-shields  with  advantage,  when 
she  is  not  nursing.  In  this  way  these  troublesome  complications  may 
generally  be  prevented.  The  most  common  forms  are  either  an  abra- 
sion on  the  surface  of  the  nipple,  which,  if  neglected,  may  form  a 
small  ulcer,  or  a  crack  at  some  part  of  the  nipple,  most  generally  at 
its  base.  In  either  case,  the  suffering  when  the  child  is  put  to  the 
breast  is  intense,  sometimes  indeed  amounting  to  intolerable  anguish, 
causing  the  mother  to  look  forward  with  dread  to  the  application  of 
the  child.  Whenever  such  pain  is  complained  of,  the  nipple  should 
be  carefully  examined,  since  the  fissure  or  sore  is  often  so  minute  as 
to  escape  superficial  examination.  The  remedies  recommended  are 
very  numerous,  and  not  always  successful.     Amongst  those  most 


560  THE    PUERPERAL    STATE. 

commonly  used  are  astringent  applications,  such  as  tannin,  or  weak 
solutions  of  nitrate  of  silver,  or  cauterizing  the  edges  of  the  fissure 
with  the  solid  nitrate  of  silver,  or  applying  the  flexible  collodion  of 
the  Pharmacopoeia.  Dr.  Wihson,  of  Glasgow,  speaks  highly  of  a 
lotion  composed  of  ten  grains  of  nitrate  of  lead  in  an  ounce  of  gly- 
cerine, which  is  to  be  applied  after  suckling,  the  nipple  being  care- 
fully washed  before  the  child  is  again  put  to  the  breast.  I  have 
myself  found  nothing  answer  so  well  as  a  lotion  composed  of  half  an 
ounce  of  sulphurous  acid,  half  an  ounce  of  the  glycerine  of  tannin, 
and  an  ounce  of  water,  the  beneficial  effects  of  which  are  sometimes 
quite  remarkable,  Eelief  may  occasionally  be  obtained  by  inducing 
the  child  to  suck  through  a  nipple-shield,  especially  when  there  is 
only  an  excoriation  ;  but  this  will  not  always  answer,  on  account  of 
the  extreme  pain  which  it  produces. 

Excessive  Flow  of  Milh. — An  excessive  flow  of  milk,  knoAvn  as 
galactorrhoea,  often  interferes  with  successful  lactation.  It  is  by  no 
means  rare  in  the  first  weeks  after  delivery  for  women  of  delicate 
constitution,  who  are  really  unfit  to  nurse,  to  be  flooded  with  a  super- 
abundance of  watery  and  innutritions  milk,  which  soon  produces 
disordered  digestion  in  the  child.  Under  such  circumstances,  the 
only  thing  to  be  done  is  to  give  up  an  attempt  which  is  injurious 
both  to  the  mother  and  child.  At  a  later  stage  the  milk,  secreted  in 
large  quantities,  is  sufficiently  nourishing  to  the  child,  but  the  drain 
on  the  mother's  constitution  soon  begins  to  tell  on  her.  Palpitation, 
giddiness,  emaciation,  headache,  loss  of  sleep,  spots  before  the  eyes, 
and  even  amaurosis,  indicate  the  serious  effects  which  are  being  pro- 
duced, and  the  absolute  necessity  of  at  once  stopping  lactation. 
Whenever,  therefore,  a  nursing  woman  suffers  from  such  symptoms, 
it  is  far  better  at  once  to  remove  the  cause,  otherAvise  a  very  serious 
and  permanent  deterioration  of  health  might  result. 

Mavimary  Abscess. — There  is  no  more  troublesome  complication  of 
lactation  than  the  formation  of  abscess  in  the  breast ;  an  occurrence 
by  no  means  rare,  and  which,  if  improperly  treated,  may,  by  long- 
continued  suppuration  and  the  formation  of  numerous  sinuses  in  and 
about  the  breast,  produce  very  serious  effects  on  the  general  health. 
The  causes  of  breast  abscesses  are  numerous,  and  very  trivial  circum- 
stances may  occasionally  set  up  inflammation,  ending  in  suppuration. 
Thus  it  may  follow  exposure  to  cold ;  a  blow,  or  other  injury  to  the 
breast ;  some  temporary  engorgement  of  the  lacteal  tubes ;  or  even 
sudden  or  depressing  mental  emotions.  The  most  frequent  cause  is 
irritation  from  fissures  or  erosions  of  the  nipples,  which  must,  there- 
fore, always  be  regarded  with  suspicion,  and  cured  as  soon  as 
possible. 

Signs  and  Symptoms. — The  abscess  may  form  in  any  part  of  the 
breast,  or  in  the  areolar  tissue  below  it ;  in  the  latter  case,  the  in- 
flammation very  generally  extends  to  the  gland  structure.  Abscess 
is  usually  ushered  in  by  constitutional  symptoms,  varying  in  severity 
with  the  amount  of  the  inflammation.  Pyrexia  is  always  present ; 
elevated  temperature,  rapid  pulse,  and  much  malaise  and  sense  of 
feverishness,  followed,  in  many  cases,  by  distinct  rigor,  when  deep- 


MANAGEMENT    OF    THE    INFANT,    LACTATION,    ETC.  561 

seated  suppuration  is  taking  place.  On  examining  the  breast  it  will 
be  found  to  be  generally  enlarged  and  very  tender,  while,  at  the  site 
of  the  abscess,  an  indurated  and  painful  swelling  may  be  felt.  If  the 
inflammation  be  chiefly  limited  to  the  subglandular  areolar  tissue, 
there  may  be  no  localized  swelling  felt,  but  the  whole  breast  will  be 
acutely  sensitive,  and  the  slightest  movement  will  cause  much  pain. 
As  the  case  progresses,  the  abscess  becomes  more  and  more  super- 
ficial, the  skin  covering  it  is  red  and  glazed,  and  if  left  to  itself,  it 
bursts.  In  the  more  serious  cases,  it  is  by  no  means  rare  for  multiple 
abscesses  to  form.  These  opening,  one  after  the  other,  lead  to  the 
formation  of  numerous  fistulous  tracts,  by  which  the  breast  may  be- 
come completely  riddled.  Sloughing  of  portions  of  the  gland-tissue 
may  take  place,  and  even  considerable  hemorrhage,  from  the  de- 
struction of  bloodvessels.  The  general  health  soon  suffers  to  a 
marked  degree,  and,  as  the  sinuses  continue  to  suppurate  for  many 
successive  months,  it  is  by  no  means  uncommon  for  the  patient  to  be 
reduced  to  a  state  of  profound  and  even  dangerous  debility. 

Treatment. — Much  may  be  done  by  proper  care  to  prevent  the 
formation  of  abscess,  especially  by  removing  engorgement  of  the 
lacteal  ducts,  when  threatened,  by  gentle  hand  friction  in  the  manner 
already  indicated.  When  the  general  symptoms,  and  the  local  ten- 
derness, indicate  that  inflammation  has  commenced,  we  should  at 
once  endeavor  to  moderate  it,  in  the  hope  that  resolution  may  occur 
without  the  formation  of  pus.  Here  general  principles  must  be 
attended  to,  especially  giving  the  aii'ected.  part  as  much  rest  as  pos- 
sible. Feverishness  may  bo  combated  by  gentle  saline,  minute  doses 
of  aconite,  and  large  doses  of  quinine  ;  while  pain  should  be  relieved 
by  opiates.  The  patient  should  be  strictly  confined  in  bed,  and  the 
affected  breast  supported  by  a  suspensory  bandage.  Warmth  and 
moisture  are  the  best  means  of  relieving  the  local  pain,  either  in  the 
form  of  hot  fomentations,  or  of  light  poultices  of  linseed-meal  or 
bread  and  milk,  and  the  breast  may  be  smeared  with  extract  of  bella- 
donna rubbed  down  with  glycerine,  or  the  belladonna  liniment' 
sprinkled  over  the  surface  of  the  poultices.  Generally  the  pain  and 
irritation  produced  by  putting  the  child  to  the  breast  are  so  great  as 
to  contra-indicate  nursing  from  the  affected  side  altogether,  and  we 
must  trust  to  relieving  the  tension  by  poultices;  suckling  being,  in 
the  mean  time,  carried  on  by  the  other  breast  alone.  In  favorable 
cases  this  is  quite  possible  for  a  time,  and  it  may  be  that,  if  the  in- 
flammation do  not  end  in  suppuration,  or  if  the  abscess  be  small  and 
localized,  the  affected  breast  is  again  able  to  resume  its  functions. 
Often  this  is  not  possible,  and  it  may  be  advisable,  in  severe  cases,  to 
give  up  nursing  altogether. 

PiLS  sliould  he  Removed  as  soon  as  Possible.— The  subsequent  man- 
agement of  the  case  consists  in  the  opening  of  the  abscess  as  soon  as 
the  existence  of  pus  is  ascertained,  either  by  fluctuation,  or,  if  the 
site  of  the  abscess  be  deep-seated,  by  the  exploring  needle.  It  may 
be  laid  down  as  a  principle,  that  the  sooner  the  pus  is  evacuated  the 
better,  and  nothing  is  to  be  gained  by  waiting  until  it  is  superficial. 


502  THE    PUERPERAL    STATE. 

On  tbe  contrary,  such  delay  only  leads  to  more  extensive  disorgani- 
;^ation  of  tissue  and  the  further  spread  of  inflammation. 

Antise2}tiG  Treatment. — The  method  of  opening  the  abscess  is  of 
primary  importance.  It  has  always  been  customary  simply  to  open 
the  abscess  at  its  most  depending  part,  without  using  any  precaution 
against  tbe  admission  of  air,  and  afterwards  to  treat  secondary  ab- 
scesses in  the  same  way.  Tbe  results  are  well  known  to  all  practical 
accoucheurs,  and  the  records  of  surgery  fully  show  how  many  weeks 
or  montbs  generally  elapse  in  bad  cases  before  recovery  is  complete. 
The  antiseptic  treatment  of  mammary  abscess,  in  tbe  way  first 
pointed  out  by  Lister,  afford  results  which  are  of  the  most  remark- 
able and  satisfactory  kind.  Instead  of  being  Aveeks  and  months  in 
healing,  I  believe  that  the  practitioner  who  fairly  and.  minutely  car- 
ries out  Mr.  Lister's  directions  may  confidently  look  for  complete 
closure  of  the  abscess  in  a  few  days ;  and  I  know  nothing,  in  the 
whole  range  of  my  professional  experience,  that  has  given  me  more 
satisfaction  than  the  application  of  this  method  to  abscesses  of  the 
breast.  The  plan  I  first  used  is  that  recommended  by  Lister  in  the 
"Lancet"  for  1867,  but  which  is  now  superseded  by  his  improved 
methods,  which  of  course,  will  be  used  in  preference  by  all  who 
have  made  themselves  familiar  with  the  details  of  antiseptic  surgery. 
The  former,  however,  is  easily  Avithin  the  reach  of  every  one,  and  is 
so  simple  that  no  special  skill  or  practice  is  required  in  its  applica- 
tion ;  whereas  the  more  perfected  antiseptic  appliances  will  probably 
not  be  so  readily  obtained,  and  are  much  more  difficult  to  use.  I, 
therefore,  insert  Mr.  Lister's  original  directions,  which  he  assures  me 
are  perfectly  aseptic,  for  the  guidance  of  those  Avho  may  not  be  able 
to  obtain  the  more  elaborate  dressings: — "A  solution  of  one  part  of 
crystallized  carbolic  acid  in  four  parts  of  boiled  linseed  oil  having 
been  prepared,  a  piece  of  rag  from  four  to  six  inches  square  is  dipped 
into  the  oily  mixture,  and  laid  upon  the  skin  where  the  incision  is  to 
be  made.  The  lower  edge  of  the  rag  being  then  raised,  while  the 
upper  edge  is  kept  from  slipping  by  an  assistant,  a  common  scalpel 
or  bistoury  dipped  in  the  oil  is  plunged  into  the  cavity  of  the  ab- 
scess, and  an  opening  about  three-quarters  of  an  inch  in  length  is 
made,  and  the  instant  the  knife  is  withdrawn  the  rag  is  dropped 
upon  the  skin  as  an  antiseptic  curtain,  beneath  which  the  pus  flows 
out  into  a  vessel  placed  to  receive  it.  The  cavity  of  the  abscess  is 
firmly  pressed,  so  as  to  force  out  all  existing  pus  as  nearly  as  may  be 
(the  old  fear  of  doing  mischief  by  rough  treatment  of  the  pyogenic 
membrane  being  quite  ill-founded) ;  and  if  there  be  much  oozing  of 
blood,  or  if  there  be  considerable  thickness  of  parts  between  the 
abscess  and  the  surface,  a  piece  of  lint  dipped  in  the  antiseptic  oil  is 
introduced  into  the  incision  to  check  bleeding  and  ])revent  primary 
adhesion,  which  is  otherwise  very  apt  to  occur.  The  introduction 
of  the  lint  is  effected  as  rapidly  as  may  be,  and  under  the  protection 
of  the  antiseptic  rag.  Thus  the  evacuation  of  the  original  contents 
is  accomplished  with  perfect  security  against  the  introduction  of 
living  germs.  This,  however,  would  be  of  no  avail  unless  an  anti- 
septic dressing  could  be  applied  that  would  effectually  prevent  the 


MANAGEMENT    OF    THE    INFANT,    LACTATION,    ETC.  56B 

decomposition  of  the  streairi  of  pus  constantly  flowing  out  beneath  it. 
After  numerous  disappointments,  I  have  succeeded  with  the  follow- 
ing, which  may  be  relied  upon  as  absolutely  trustworthy:  About 
six-teaspoonfuls  of  the  above-mentioned  solution  of  carbolic  acid  in 
linseed  oil  are  mixed  up  with  common  whiting  (carbonate  of  lime) 
to  the  consistence  of  a  hrm  paste,  which  is,  in  fact,  glazier's  putty 
with  the  addition  of  a  little  carbolic  acid.  This  is  spread  upon  a 
piece  of  common  tin-foil  about  six  inches  square,  so  as  to  form  a 
layer  about  a  quarter  of  an  inch  thick.  The  tin-foil,  thus  spread 
with  putty,  is  placed  upon  the  skin,  so  that  the  middle  of  it  corre- 
sponds to  the  position  of  the  incision,  the  antiseptic  rag  used  in 
opening  the  abscess  being  removed  the  instant  before.  Tlie  tin  is 
then  fixed  securely  by  adhesive  plaster,  the  lowest  edge  being  left 
free  for  the  escape  of  the  discharge  into  a  folded  towel  placed  over 
it  and  secured  by  a  bandage.  The  dressing  is  changed,  as  a  general 
rule,  once  in  24  hours,  but,  if  the  abscess  be  a  very  large  one,  it  is 
prudent  to  see  the  patient  12  hours  after  it  has  been  opened,  when, 
if  the  towel  should  be  much  stained  with  discharge,  the  dressing 
should  be  changed,  to  avoid  subjecting  its  antiseptic  virtues  to  too 
severe  a  test.  But  after  the  first  24  hours  a  single  daily  dressing 
is  suf&cient.  The  changing  of  the  dressing  must  be  methodically 
done  as  follows :  A  second  similar  piece  of  tin-foil  having  been 
spread  with  the  putty,  a  piece  of  rag  is  dipped  in  the  oily  solution 
and  placed  on  the  incision  the  moment  the  first  tin  is  removed.  This 
guards  against  the  possibility  of  mischief  occurring  during  the  cleans- 
ing of  the  skin  with  a  dry  cloth,  and  pressing  out  any  discharge 
which  may  exist  in  the  cavity.  If  a  plug  of  lint  was  introduced 
when  the  abscess  was  opened,  it  is  removed  under  cover  of  the  anti- 
septic rag,  which  is  taken  off  at  the  moment  when  the  new  tin  is  to 
be  applied.  The  same  process  is  continued  daily  until  the  sinus 
closes." 

Treatment  of  Lowj-coniinued  Suppuration  and  Fever. — If  the  case 
come  under  our  care  when  the  abscess  has  been  long  discharging,  or 
when  sinuses  have  formed,  the  treatment  is  directed  mainly  to  pro- 
curing a  cessation  of  suppuration  and  closure  of  the  sinuses.  For 
this  purpose  methodical  strapping  of  the  breast  with  adhesive  plaster, 
so  as  to  afford  steady  support  and  compress  the  opposing  pyogenic 
surfaces,  will  give  the  best  results.  It  may  be  necessary  to  lay  open 
some  of  the  sinuses,  or  to  inject  tinct.  iodi  or  other  stimulating  lotions, 
so  as  to  moderate  the  discharge,  the  subsequent  surgical  treatment 
varying  according  to  the  requirements  of  each  case.  As  the  drain 
on  the  system  is  great,  and  the  constitutional  debility  generally  pro- 
nounced, much  attention  must  be  paid  to  general  treatment ;  and 
abundance  of  nourishing  food,  appropriate  stimulants,  and  such 
medicines  as  iron  and  quinine,  will  be  indicated. 

Hand-feedinrj . — In  a  considerable  number  of  cases  the  inability  of 
the  mother  to  nurse  the  child,  her  invincible  repugnance  to  a  wet 
nurse,  or  inability  to  bear  the  expense,  renders  hand-feeding  essen- 
tial. It  is,  therefore,  of  importance  that  the  accoucheur  should  be 
thoroughly  familiar  with  the  best  method  of  bringing  up  the  child 


564  THE    PUERPERAL    STATE. 

by  hand,  so  as  to  be  able  to  direct  tlie  process  in  the  way  that  is 
most  likely  to  be  successful. 

Causes  of  Mortality  in  Hand-fed  Children. — Much  of  the  mortality 
following  hand-feeding  may  be  traced  to  unsuitable  food.  Among 
the  poorer  classes  especially  there  is  a  prevalent  notion  that  milk 
alone  is  insufficient ;  and  hence  the  almost  universal  custom  of  ad- 
ministering various  farinaceous  foods  .such  as  corn-flour  or  arrow- 
root, even  from  the  earliest  period.  Many  of  these  consist  of  starch 
alone,  and  are  therefore  absolutely  unsuited  for  forming  the  staple 
of  diet,  on  account  of  the  total  absence  of  nitrogenous  elements. 
Independently  of  this,  it  has  been  shown  that  the  saliva  of  infants 
has  not  the  same  digestive  property  on  starch  that  it  subsequently 
acquires,  and  this  aiibrds  a  further  explanation  of  its  so  constantly 
producing  intestinal  derangement.  Eeason,  as  well  as  experience, 
abundantly  prove  that  the  object  to  be  aimed  at  in  hand-feeding  is 
to  imitate  as  nearly  as  possible  the  food  which  nature  supplies  for 
the  new-born  child,  and  therefore  the  obvious  course  is  to  use  milk 
from  some  animal,  so  treated  as  to  make  it  resemble  human  milk 
as  nearly  as  may  be. 

Ass's  Milk.- — Of  the  various  milks  used,  that  of  the  ass,  on  the 
whole,  most  closely  resembles  human  milk,  containing  less  casein 
and  butter,  and  more  saline  ingredients.  It  is  not  always  easy  to 
obtain,  and  in  towns  is  excessively  expensive.  Moreover,  it  does  not 
always  agree  with  the  child,  being  apt  to  produce  diarrhoea.  "We 
can,  however,  be  more  certain  of  its  being  unadulterated,  which  in 
large  cities  is  in  itself  no  small  advantage,  and  it  maybe  given  with- 
out the  addition  of  water  or  sugar. 

Goat's  milk  in  this  country  is  still  more  difficult  to  obtain,  but  it 
often  succeeds  admirably.  In  many  places  the  infant  sucks  the  teat 
directly,  and  certainly  thrives  well  on  the  plan. 

[We  reverse  the  order  in  this  country,  where  the  ass  is  seldom 
seen,  and  the  goat  quite  common,  particularly  in  the  suburbs  of  our 
large  cities  where  its  milk  is  most  required.  I  have  seen  marvellous 
results  from  feeding  sick  infants  with  its  milk  freshly  drawn,  and 
diluted  with  hot  Avater.  I  do  not  believe  its  milk  is  as  suitable  as 
that  of  the  cow,  but  it  has  the  advantage  that  it  can  be  obtained 
freshly  drawn  in  a  city,  by  keeping  the  animal  in  the  yard,  or  on  a 
vacant  lot.  The  goat  should  be  fed  upon  grass  and  other  suitable 
diet,  and  not  permitted  to  run  at  large,  as  it  eats  with  impunity, 
stramonium  and  other  noxious  weeds. — Ed.] 

Colo's  Milk  audits  Preparation. — In  a  large  majority  of  cases  we 
have  to  rely  on  cow's  milk  alone.  It  differs  from  human  milk  in 
containing  less  water,  a  larger  amount  of  casein  and  solid  matters, 
and  less  sugar.  Therefore,  before  being  given,  it  requires  to  be 
diluted  and  sweetened.  A  common  mistake  is  over  dilution,  and  it 
is  far  from  rare  for  nurses  to  administer  one- third  cow's  milk  to  two- 
thirds  water.  The  result  of  this  excessive  dilution  is,  that  the  child 
•  becomes  pale  and  puny,  and  has  none  of  the  firm  and  plump  appear- 
ance of  a  well-fed  infant.  The  practitioner  should,  therefore,  ascer- 
tain that  this  mistake  is  not  being  made ;  and  the  necessary  dilution 


MANAGEMENT    OF    THE    INFANT,    LACTATION,    ETC.  565 

will  be  best  obtained  by  adding  to  pure  fresh  cow's  milk,  oue-tliird 
hot  water,  so  as  to  warm  the  mixture  to  about  96^,  the  whole  being 
slightly  sweetened  with  sugar  of  milk,  or  ordinary  crystallized  sugar. 
After  the  first  two  or  three  months  the  amount  of  water  may  be 
lessened,  and  pure  milk,  warmed  and  sweetened,  given  instead.' 
Whenever  it  is  possible,  the  milk  should  be  obtained  from  the  same 
cow,  and  in  towns  some  care  is  requisite  to  see  that  the  animal  is 
properly  fed  and  stabled.  Of  late  years  it  has  been  customary  to 
obviate  the  difficulties  of  obtaining  good  fresh  milk  by  using  some 
of  the  tinned  milks  now  so  easily  to  be  had.  These  are  already 
sweetened,  and  sometimes  answer  well,  if  not  given  in  too  weak  a 
dilution.  One  great  drawback  in  bottle-feeding  is  the  tendency  of 
the  milk  to  become  acid,  and  hence  to  produce  diarrha^a.  This  may 
be  obviated  to  a  great  extent  by  adding  a  tablespoonful  of  lime-water 
to  each  bottle,  instead  of  an  equal  quantity  of  water. 

Artificial  Human  Milk. — An  admirable  plan  of  treating  coav's  milk, 
so  as  to  reduce  it  to  almost  absolute  chemical  identity  with  human 
milk,  has  been  devised  by  Professor  Frankland,  to  whom  I  am  in- 
debted for  permission  to  insert  the  receipt.  1  have  followed  this 
method  in  many  cases,  and  find  it  far  superior  to  the  usual  one,  as 
it  produces  an  exact  and  uniform  compound.  With  a  little  practice 
nurses  can  employ  it  with  no  more  trouble  than  the  ordinary  mixing 
of  cow's  milk  with  water  and  sugar.  The  following  extract  from 
Dr.  Frankland's  work^  will  explain  the  principles  on  which  the  prep- 
aration of  the  artificial  human  milk  is  founded:  "The  rearing  of 
infants  who  cannot  be  supplied  with  their  natural  food  is  notoriously 
difficult  and  uncertain,  owing  chiefly  to  the  great  difference  in  the 
chemical  composition  of  human  milk  and  cow's  milk.  The  latter  is 
much  richer  in  casein  and  poorer  in  milk-sugar  than  the  former, 
whilst  asses'  milk,  which  is  sometimes  used  for  feeding  infants,  is 
too  poor  in  casein  and  butter,  although  the  proportion  of  sugar  is 
nearly  the  same  as  in  human  milk.  The  relations  of  the  three  kinds 
of  milk  to  each  other  are  clearly  seen  from  the  following  analytical 
numbers,  which  express  the  percentage  amounts  of  the  different 
constituents : — 

Woman.  Ass.  Cow. 

Casein 2.7  1.7  4.2 

Butter 3.5  1.3  3.8 

Milk-sugar 5.0  4.5  3.8 

Salts .2  .5  .7 

These  numbers  show  that  by  the  removal  of  one-third  of  the  casein 
from  cow's  milk  and  the  addition  of  about  one-third  more  milk-sugar 
a  liquid  is  obtained  which  closely  approaches  human  milk  in  compo- 

r'  I  have  been  obliged  with  quite  young  infants  in  some  instances,  to  change  from 
Alderney  to  common  cow's  milk,  as  the  larger  pi-oportion  of  butter  in  the  fonner 
makes  it  too  unlike  that  of  the  woman  to  agree  with  the  child.  It  is  well  to  recom- 
mend the  milk  of  one  cow,  but  many  who  claim  to  bring  it,  fill  the  little  can  out  of  the 
big  one,  on  their  round  in  the  city.  A  A'ery  young  cow  and  an  old  one  are  not 
suitable.     In  country  practice,  the  selected  cow  system  is  often  quite  effective. — Ed-I 

^  Frankland's  Experimental  Research(!S  in  Chemistry,  p.  843. 


Obb  THE    PUERPERAL    STATE. 

sition,  the  percentage  amounts  of  the  four  chief  constituents  being 
as  follows : — 

Casein  ...........         2.8 

Butter 3.8 

Milk-sugar 5.0 

Salts 7 

The  following  is  the  mode  of  preparing  the  milk :  Allow  one-third 
of  a  pint  of  new  milk  to  stand  for  about  twelve  hours,  remove  the 
cream,  and  add  to  it  two-thirds  of  a  pint  of  new  milk,  as  fresh  from 
the  cow  as  possible.  Into  the  one-third  of  a  pint  of  blue  milk  left 
after  the  abstraction  of  the  cream  put  a  piece  of  rennet  about  one 
inch  square.  Set  the  vessel  in  warm  water  until  the  milk  is  fully- 
curdled,  an  operation  requiring  from  five  to  fifteen  minutes  accord- 
ing to  the  activity  of  the  rennet,  which  should  be  removed  as  soon 
as  the  curdling  commences,  and  put  into  an  egg-cup  for  use  on  sub- 
sequent occasions,  as  it  may  be  employed  daily  for  a  month  or  two. 
Break  up  the  curd  repeatedly,  and  carefully  separate  the  whole  of 
the  whey,  which  should  then  be  rapidly  heated  to  boiling  in  a  small 
tin  pan  placed  over  a  spirit  or  gas  lamp.  During  the  heating  a 
further  quantity  of  casein  technicallj''  called  'fleetings'  separates, 
and  must  be  removed  by  straining  through  muslin.  Now  dissolve 
110  grains  of  powdered  sugar  of  milk  in  the  hot  whey,  and  mix  it 
with  the  two-thirds  of  a  pint  of  new  milk  to  which  the  cream  from 
the  other  tliird  of  a  pint  was  added  as  alread}'-  described.  The  arti- 
ficial milk  should  be  used  within  twelve  hours  of  its  preparation, 
and  it  is  almost  needless  to  add  that  all  the  vessels  emploj^ed  in  its 
manufacture  and  administration  should  be  kept  scrupulously  clean." 
Method  of  Hand-feeding. — Much  of  the  success  of  bottle-feeding 
must  depend  on  minute  care  and  scrupulous  cleanliness,  points  which 
cannot  be  too  strongly  insisted  on.  Particular  attention  should  be 
paid  to  preparing  the  food  fresh  for  every  meal,  and  to  keeping  the 
feeding-bottle  and  tubes  constantly  in  water  when  not  in  use,  so  that 
minute  particles  of  milk  may  not  remain  about  them  and  become 
sour.  A  nesflect  of  this  is  one  of  the  most  fertile  sources  of  the 
thrush  from  which  bottle-fed  infants  often  suffer.  The  particular 
form  of  bottle  used  is  not  of  much  consequence.  Those  now  com- 
monly employed,  with  a  long  india-rubber  tube  attached,  are  prefer- 
able to  the  older  forms  of  flat  bottle,  as  they  necessitate  strong  suc- 
tion on  the  part  of  the  infant,  thus  forcing  it  to  swallow  the  food 
more  slowly.  Care  must  be  taken  to  give  the  meals  at  stated  periods, 
as  in  breast- feeding^,  and  these  should  be  at  first  about  two  hours 
apart,  the  intervals  being  gradually  extended.  The  nurse  should  be 
strictly  cautioned  against  the  common  practice  of  placing  the  bottle 
beside  the  infant  in  its  cradle,  and  allowing  it  to  suck  to  repletion,  a 
practice  which  leads  to  over-distension  of  the  stomach,  and  conse- 
quent dyspepsia.  The  child  should  be  raised  in  the  arms  at  the 
proper  time,  have  its  food  administered,  and  then  be  replaced  in  the 
cradle  to  sleep.  In  the  first  few  weeks  of  bottle-feeding  constipation 
is  very  common,  and  may  be  effectually  remedied  by  placing  as 


MANAGEMENT    OF    THE    INFANT,    LACTATION,    ETC.  567 

much  phosphate  of  soda  as  will  lie  on  a  threepenny-piece  in  the 
bottle,  two  or  three  times  in  the  twenty-four  hours. 

Other  kinds  of  Food. — If  this  system  succeed,  no  other  food  should 
be  given  uutil  the  child  is  six  or  seven  months  old,  and  then  some 
of  the  various  infant's  food  may  be  cautiously  commenced.  Of  these 
there  are  an  immense  number  in  common  use  ;  some  of  which  are 
good  articles  of  diet,  others  are  unfitted  for  infants.  In  selecting 
them  we  have  to  see  that  they  contain  the  essential  elements  of  nutri- 
tion in  proper  combination.  All  those,  therefore,  that  are  purelv 
starchy  in  character,  such  as  arrowroot,  corn-flour,  and  the  like, 
should  be  avoided ;  while  those  that  contain  nitrogenous  as  well  as 
starch  elements,  may  be  safely  given.  Of  the  latter  the  entire 
wheat  flour,  which  contains  the  husks  ground  down  with  the  wheat, 
generally  answers  admirably  ;  and  of  the  same  character  are  rusks, 
tops  and  bottoms,  Nestle's  or  Liebig's  infant's  food,  and  many  others. 
If  the  child  be  pale  and  flabby,  some  more  purely  animal  food  mav 
often  be  given  twice  a  day,  and  great  benefit  may  be  derived  from  a 
single  meal  of  beef,  chicken,  or  veal  tea,  with  a  little  bread  crumb  in 
it,  especially  after  the  sixth  or  seventh  month.  Milk,  however,  should 
still  form  the  main  article  of  diet,  and  should  continue  to  do  so  for 
many  months. 

Management  lohen  Milk  disagrees. — If  the  child  be  pale,  flabby,  and 
do  not  gain  flesh,  more  especially  if  diarrhoea  or  other  intestinal  dis- 
turbance be  present,  we  may  be  certain  that  hand-feeding  is  not  an- 
swering satisfactorily,  and  that  some  change  is  required.  If  the  child 
be  not  too  old,  and  will  still  take  the  breast,  that  is  certainl}^  the 
best  remedy,  but  if  that  be  not  possible,  it  is  necessary  to  alter  the 
diet.  When  milk  disagrees,  cream,  in  the  proportion  of  one  table- 
spoonful  to  three  of  water,  sometimes  answers  as  well.  Occasionally 
also  Liebig's  infant's  food,  when  carefully  prepared,  renders  good 
service.  Too  often,  however,  when  once  diarrhoea  or  other  intesti- 
nal disturbance  has  set  in,  all  our  efforts  may  prove  unavailing,  and 
the  health,  if  not  the  life,  of  the  infant  becomes  seriously  imperilled. 
It  is  not,  however,  within  the  scope  of  this  work  to  treat  of  the  dis- 
orders of  infants  at  the  breast,  the  proper  consideration  of  which  re- 
quires a  large  amount  of  space,  and  I,  therefore,  refrain  from  making 
any  further  remarks  on  the  subject. 

[As  a  general  rule,  children  in  this  country  are  better  kept  exclu- 
sively on  a  milk  diet  for  at  least  ten  months,  especially  if  it  is  in  the 
summer  season.  The  best  addition  then,  is  exsiccated  wheat  flour 
prepared  by  the  process  of  Hards,  and  known  as  Hards'  farinaceous 
food,  prepared  wheat,  imperial  granum,  etc.  Ohio  groats  made  of 
the  oat  kernel,  and  prepared  barley  flour,  are  sometimes  useful  where 
the  habit  of  the  child  is  constipated. — Ed.] 


668  THE    PUERPERAL    STATE. 


CHAPTEK    III. 

PUEEPERAL  ECLAMPSIA. 

By  the  term  puerperal  eclampsia  is  meant  a  peculiar  kind  of  epi- 
leptiform convulsions,  which  may  occur  in  the  latter  months  of  preg- 
nancy, or  during,  or  after  parturition,  and  it  constitutes  one  of  the 
most  formidable  diseases  with  which  the  obstetrician  has  to  cope. 
The  attack  is  often  so  sudden  and  unexpected,  so  terrible  in  its 
nature,  and  attended  with  such  serious  danger  both  to  the  mother 
and  child,  that  the  disease  has  attracted  much  attention. 

Its  Doubtful  Etiology. — The  researches  of  Lever,  Braun,  Frerichs, 
and  many  other  writers  who  have  shown  the  frequent  association  of 
eclampsia  with  albuminuria,  have,  of  late  years,  been  supposed  to 
clear  up  to  a  great  extent  the  etiology  of  the  disease,  and  to  prove 
its  dependence  on  the  retention  of  urinary  elements  in  the  blood. 
While  the  urinar}^  origin  of  eclampsia  has  been  pretty  generally 
accepted,  more  recent  observations  have  tended  to  throw  doubt  on 
its  essential  dependence  on  this  cause ;  so  that  it  can  hardly  be  said 
that  we  are  yet  in  a  position  to  explain  its  true  pathology  with  cer- 
tainty. These  points  will  require  separate  discussion,  but  it  is  first 
necessary  to  describe  the  character  and  history  of  the  attack. 

Considerable  confusion  exists  in.  the  description  of  puerperal  con- 
avulsions  from  the  confounding  of  several  essentially  distinct  diseases 
under  the  same  name.  Thus,  in  most  obstetric  works,  it  has  been 
customary  to  describe  three  distinct  classes  of  convulsion;  the  epi- 
leptic^ the  hysterical^  and  the  apoplectic.  The  two  latter,  however, 
come  under  a  totally  different  category.  A  pregnant  woman  may 
suffer  from  hysterical  paroxysms,  or  she  may  be  attacked  with  apo- 
plexy, accoraJDanied  with  coma,  and  followed  by  paralysis.  But  these 
conditions  in  the  pregnant  or  parturient  woman  are  identical  with 
the  same  diseases  in  the  non-pregnant,  and  are  in  no  way  special  in 
their  nature.  True  eclampsia,  however,  is  different  in  its  clinical 
history  from  epilepsy;  although  the  paroxysms  while  they  last,  are 
essentially  the  same  as  those  of  an  ordinary  epileptic  fit. 

Premonitory  Symptom.s. — An  attack  of  eclampsia  seldom  occurs 
without  having  been  preceded  by  certain  more  or  less  well-marked 
precursory  symptoms.  It  is  true  that,  in  a  considerable  number  of 
cases,  these  are  so  slight  as  not  to  attract  attention,  and  suspicion  is 
not  aroused  until  the  patient  is  seized  with  convulsions.  Still,  sub- 
sequent investigations  Avill  very  generally  show  that  some  symptoms 
did  exist,  which,  if  observed  and  properly  interpreted,  might  have 
put  the  practitioner  on  his  guard,  and  possibly  enable  him  to  ward 
oft"  the  attack.    Hence  a  knowledge  of  them  is  of  real  practical  value. 


PUERPERAL  ECLAMPSIA,  569 

The  most  common  are  associated  with  the  cerebrum,  sucli  as  severe 
headache,  which  is  the  one  most  generally  observed,  and  is  sometimes 
limited  to  one  side  of  the  head.  Transient  attacks  of  dizziness,  spots 
before  the  eyes,  loss  of  sight,  or  impairment  of  the  intellectual  facul- 
ties, are  also  not  uncommon.  These  signs  in  a  pregnant  woman  are 
of  the  gravest  import,  and  should  at  once  call  for  investigation  into 
the  nature  of  the  case.  Less  marked  indications  sometimes  exist  in 
the  form  of  irritability,  slight  headache  or  stupor,  and  a  general  feel- 
ing of  indisposition.  Another  important  premonitory  sign  is  oedema 
of  the  subcutaneous  cellular  tissue,  especially  of  the  face  or  upper 
extremities,  which  should  at  once  lead  to  an  examination  of  the 
urine. 

Symptoms  of  the  Attach. — AVhether  such  indications  have  preceded 
an  attack  or  not,  as  soon  as  the  convulsion  comes  on  there  can  no 
longer  be  any  doubt  as  to  the  nature  of  the  case.  The  attack  is  gene- 
rally sudden  in  its  onset,  and  in  its  character  is  precisely  that  of  a 
severe  epileptic  fit,  or  of  the  convulsions  in  children.  Close  observa- 
tion shows  that  there  is  at  first  a  short  period  of  tonic  spasm,  affecting 
the  entire  muscular  system.  This  is  almost  immediately  succeeded 
by  violent  clonic  contractions,  generally  commencing  in  the  muscles 
of  the  face,  which  twitch  violently  ;  the  expression  is  horribly  altered; 
the  globes  of  the  eyes  are  turned  up  under  the  eyelids,  so  as  to  leave 
only  the  white  sclerotics  visible,  and  the  angles  of  the  mouth  are 
retracted  and  fixed  in  a  convulsive  grin.  The  tongue  is  at  the 
same  time  protruded  forcibly,  and,  if  care  be  not  taken,  is  apt  to  be 
lacerated  by  the  violent  grinding  of  the  teeth.  The  face,  at  first  pale, 
soon  becomes  livid  and  cyanosed,  while  the  veins  of  the  neck  are 
distended,  and  the  carotids  beat  vigorously.  Frothy  saliva  collects 
about  the  mouth,  and  the  whole  appearance  is  so  changed  as  to  render 
the  patient  quite  unrecognizable.  The  convulsive  movements  soon 
attack  the  muscles  of  the  body.  The  hands  and  arms,  at  first  rigidly 
fixed,  with  the  thumbs  clenched  into  the  palms,  begin  to  jerk,  and 
the  whole  muscular  system  is  thrown  into  rapidlv-recurring  convul- 
sive spasms.  It  is  evident  that  the  involuntary  "'muscles  are  impli- 
cated in  the  convulsive  action,  as  well  as  the  voluntary.  This  is 
shown  by  a  temporary  arrest  of  respiration  at  the  commencement  of 
the  attack,  followed  by  irregular  and  hurried  respiratory  movements, 
producing  a  pecuhar  hissing  sound.  The  occasional  involuntary  ex- 
pulsion of  urine  and  feces  indicates  the  same  fact.  During  the  attack 
the  patient  is  absolutely  unconscious,  sensibility  is  totally  suspended, 
and  she  has  afterwards  no  recollection  of  what  has  taken  place.  For- 
tunately the  convulsion  is  not  of  long  duration,  and,  at  the  outside, 
does  not  last  more  than  three  of  four  minutes,  generally  not  so  long. 
In  most  cases,  after  an  interval,  there  is  a  recurrence  of  the  convul- 
sion, characterized  by  the  same  phenomena,  and  the  paroxysms  are 
repeated  with  more  or  less  force  and  frequency  according  to  the 
severity  of  the  attack.  Sometimes  several  hours  may  elapse  before 
a  second  convulsion  comes  on ;  at  others  the  attacks  may  recur  very 
often,  with  only  a  few  minutes  between  them.  In  the  slighter  forms 
37 


570  THE    PUERPERAL    STATE. 

of  eclampsia  there  may  not  be  more  than  2  or  3  paroxysms  in  all  ; 
in  the  more  serious  as  many  as  50  or  60  have  been  recorded. 

Condition  between  the  Attacks. — After  the  first  attack  the  patient 
generally  soon  recovers  her  consciousness,  being  somewhat  dazed  and 
somnolent,  with  no  clear  perception  of  what  has  occurred.  If  the 
paroxysms  be  frequently  repeated,  more  or  less  profound  coma  con- 
tinues in  the  intervals  between  them,  which,  no  doubt,  depends  upon 
intense  cerebral  congestion,  resulting  from  the  interference  with  the 
circulation  in  the  great  veins  of  the  neck,  produced  by  spasmodic 
contraction  of  the  muscles.  The  coma  is  rarely  complete,  the  patient 
showing  signs  of  sensibility  when  irritated,  and  groaning  during  the 
uterine  contractions.  In  the  worst  class  of  cases,  the  torpor  may 
become  intense  and  continuous,  and  in  this  state  the  patient  may 
die.  When  the  convulsions  have  entirely  stopped,  and  the  patient 
has  completely  regained  her  consciousness,  and  is  apparently  conva- 
lescent, recollection  of  what  has  taken  place  during,  and  some  time 
before,  the  attack,  may  be  entirely  lost,  and  this  condition  may  last 
for  a  considerable  time,  A  curious  instance  of  this  once  came  under 
my  notice  in  a  lady  who  had  lost  a  brother  to  whom  she  was  greatly 
attached,  in  the  week  immediately  preceding  her  confinement,  and 
in  whom  the  mental  distress  seemed  to  have  had  a  good  deal  to  do 
in  determining  the  attack.  It  was  many  weeks  before  she  recovered 
her  memory,  and  during  that  time  she  recollected  nothing  about  the 
circumstances  connected  with  her  brother's  death,  the  whole  of  that 
week  being,  as  it  were,  blotted  out  of  her  recollection. 

Relation  of  the  Attacks  to  Labor. — If  the  convulsions  come  on  during 
pregnancy,  we  may  look  upon  the  advent  of  labor  as  almost  a 
certainty  ;  and  if  we  consider  the  severe  nervous  shock  and  general 
disturbance,  this  is  the  result  we  might  reasonably  anticipate.  If 
they  occur,  as  is  not  uncommon,  for  the  first  time  during  labor,  the 
pains  generally  continue  with  increased  force  and  frequency,  since 
the  uterus  partakes  of  the  convulsive  action.  It  has  not  rarely 
happened  that  the  pains  have  gone  on  with  such  intensity  that  the 
child  has  been  born  quite  unexpectedly,  the  attention  of  the  practi- 
tioner being  taken  up  with  the  patient.  In  many  cases  the  advent 
of  fresh  paroxysms  is  associated  with  the  commencement  of  a  pain, 
the  irritation  of  which  seems  sufficient  to  bring  on  the  convulsion. 

Results  to  the  Mother  and  Child. — The  results  of  eclampsia  vary 
according  to  the  severity  of  the  paroxysms.  It  is  generally  said  that 
about  1  in  3  or  4  cases  dies.  The  mortality  has  certainly  lessened  of 
late  years,  probably  in  consequence  of  improved  knowledge  of  the 
nature  of  the  disease,  and  more  rational  modes  of  treatment.  This 
is  well  shown  by  Barker,^  who  found  in  1855  a  mortality  of  32  per 
cent,  in  cases  occurring  before  and  during  labor,  and  22  per  cent,  in 
those  after  labor;  while  since  that  date  the  mortality  has  fallen  to 
14  per  cent.  The  same  conclusion  is  arrived  at  by  Dr.  Phillips,^ 
who  has  shown  that  the  mortality  has  greatly  lessened  since  the 
practice  of  repeated  and  indiscriminate  bleeding,  long  considered  the 

>  The  Puerperal  Disease,  p.  125.  «  Guy's  Hosp.  Eeps,,  1870. 


PUERPERAL    ECLAMPSIA.  571 

sheet  anchor  in  the  disease,  has  been  discontinued,  and  the  adminis- 
tration of  chloroform  substituted. 

Cause  of  Death. — Death  may  occur  during  the  parox3^sm,  and  then 
it  may  be  due  to  the  h)ng  continuance  of  the  tonic  spasm  producing 
asphyxia.  It  is  certain  that,  as  long  as  the  tonic  spasm  lasts,  the 
respiration  is  suspended,  just  as  in  the  convulsive  disease  of  children 
known  as  laryngismus  stridulus ;  and  it  is  possible  also  that  the  heart 
may  share  in  the  convulsive  contraction  which  is  known  to  affect 
other  involuntary  muscles.  More  frequently,  death  happens  at  a 
later  period,  from  the  combined  effects  of  exhaustion  and  asphj^xia. 
The  records  of  post-mortem  examinations  are  not  numerous ;  in  those 
we  possess  the  principal  changes  have  been  an  anaemic  condition  of 
the  brain,  with  some  oedematous  infiltration.  In  a  few  rare  cases 
the  convulsions  have  resulted  in  effusion  of  blood  into  the  ventricles, 
or  at  the  base  of  the  brain.  The  prognosis  as  regards  the  child  is 
also  serious.  Out  of  36  children,  Hall  Davis  found  26  born  alive, 
10  being  still-born.  There  is  good  reason  to  believe  that  the  con- 
vulsion may  attack  the  child  in  utero  ;  of  this  several  examples  are 
mentioned  by  Cazeaux ;  or  it  may  be  subsequently  attacked  with 
convulsions,  even  when  apparently  healthy  at  birth. 

Pathology  of  the  Disease. — The  precise  pathology  of  eclampsia 
cannot  be  considered  by  any  means  satisfactorily  settled.  When,  in 
the  year  184:3,  Lever  first  showed  that  the  urine  in  patients  suffering 
from  puerperal  convulsions  was  generally  highly  charged  with  albu- 
men— a  fact  which  subsequent  experience  has  amply  confirmed — it 
was  thought  that  a  key  to  the  etiology  of  the  disease  had  been  found. 
It  was  known  that  chronic  fornis  of  Bright's  disease  were  frequently 
associated  with  retention  of  urinary  elements  in  the  blood,  and  not 
rarely  accompanied  by  convulsions.  The  natural  inference  As^as 
drawn,  that  the  convulsions  of  eclampsia  Avere  also  due  to  toxaemia 
resulting  from  the  retention  of  urea  in  the  blood,  just  as  in  the 
uraemia  of  chronic  Bright's  disease ;  and  this  view  was  adopted  and 
supported  by  the  authority  of  Braun,  Frerichs,  and  many  other 
writers  of  eminence,  and  was  pretty  generally  received  as  a  satisfac- 
tory explanation  of  the  facts.  Frerichs  modified  it  so  far,  that  he 
held  that  the  true  toxic  element  was  not  urea  as  such,  but  carbonate 
of  ammonia,  resulting  from  its  decomposition  ;  and  experiments  were 
made  to  prove  that  the  injection  of  this  substance  into  the  veins  of 
the  lower  animals  produced  convulsions  of  precisely  the  same  char- 
acter as  eclampsia.  Dr.  Hammond,*  of  Maryland,  subsequently  made 
a  series  of  counter  experiments,  which  were  held  as  proving  that 
there  was  no  reason  to  believe  that  urea  ever  did  become  decom- 
posed in  the  blood  in  the  way  that  Frerichs  supposed,  or  that  the 
symptoms  of  uraemia  were  ever  produced  in  this  way.  Spiegelberg^ 
has,  more  recently,  again  examined  the  question  both  clinically,  in 
a  patient  suffering  from  convulsions,  in  whose  blood  an  excess  of 
ammonia  and  urea  was  found,  and  by  experiments  on  dogs,  and 
maintains  the  accuracy  of  Frerich's  views.     Others  have  believed 

I  Amer.  Journ.,  18G1.  2  Arch.  f.  Gyn,,  1870. 


672  THE    PUERPERAL    STATE. 

that  the  poisonous  elements  retained  in  the  blood  are  not  urea  or 
the  products  of  its  decomposition,  but  other  extractive  matters  which 
have  escaped  detection.  As  time  elapsed,  evidence  accumulated  to 
show  that  the  relation  between  albuminuria  and  eclampsia  was  not 
so  universal  as  was  supposed,  or  at  least  that  some  other  factors 
were  necessary  to  explain  many  of  the  cases.  Numerous  cases  were 
observed  in  which  albumen  was  detected  in  large  quantities,  without 
any  convulsion  following,  and  that,  not  only  in  women  who  had  been 
the  subject  of  Bright's  disease  before  conception,  but  also  when  the 
albdminuria  was  known  to  have  developed  during  pregnancy.  Thus 
Imbert  Goubeyre  found  that  out  of  164:  cases  of  the  latter  kind,  95 
had  no  eclampsia ;  and  Blot,  out  of  41  cases,  found  that  3-1  were 
delivered  without  untoward  symptoms.  It  may  be  taken  as  proved, 
therefore,  that  albuminuria  is  by  no  means  necessarily  accompanied 
by  eclampsia.  Cases  were  also  observed  in  which  the  albumen  only 
appeared  after  the  convulsion  ;  and  in  these  it  was  evident  that  the 
retention  of  urinary  elements  could  not  have  been  the  cause  of  the 
attack ;  and  it  is  highly  probable  that  in  them  the  albuminuria  was 
produced  by  the  same  cause  which  induced  the  convulsion.  Special 
attention  has  been  called  to  this  class  of  cases  by  Braxton  Hicks/ 
who  has  recorded  a  considerable  number  of  them.  He  says  that  the 
nearly  simultaneous  appearance  of  albuminuria  and  convulsion — and 
it  is  admitted  that  the  two  are  almost  invariably  combined — must 
then  be  explained  in  one  of  three  ways. 

1st.  That  the  convulsions  are  the  cause  of  the  nephritis. 

2dly.  That  the  convulsions  and  the  nephritis,  are  produced  by 
the  same  cause,  e.  g.,  some  detrimental  ingredient  circulating  in  the 
blood,  irritating  both  the  cerebro-spinal  system  and  other  organs  at 
the  same  time. 

3dly.  That  the  highly  congested  state  of  the  venous  system,  in- 
duced by  the  spasm  of  the  glottis  in  eclampsia,  is  able  to  produce  the 
kidney  complication. 

Theory  of  Trauhe  and  Rosenstein. — More  recently  Traube  and  Eo- 
senstein  have  advanced  a  theory  of  eclampsia,  purporting  to  explain 
these  anomalies.  They  refer  the  occurrence  of  eclampsia  to  acute 
cerebral  anaemia,  resulting  from  changes  in  the  blood  incident  to  preg- 
nancy. The  primary  factor  is  the  hydrtemic  condition  of  the  blood, 
which  is  an  ordinary  concomitant  of  the  pregnant  state,  and,  of  course 
when  there  is  also  albuminuria,  the  watery  condition  of  the  blood  is 
greatly  intensified  ;  hence  the  frequent  association  of  the  two  states. 
Accompanying  this  condition  of  the  blood,  there  is  increased  tension 
of  the  arterial  system,  which  is  favored  by  the  hypertrophy  of  the 
heart  which  is  known  to  be  a  normal  occurrence  in  pregnancy.  The 
result  of  these  combined  states  is  a  temporary  hyperasmia  of  the  brain, 
which  is  rapidly  succeeded  by  serous  effusion  into  the  cerebral  tissues, 
resulting  in  pressure  on  its  minute  vessels,  and  consequent  anaemia. 
There  is  much  in  this  theory  that  accords  with  the  most  recent  views 
as  to  the  etiology   of  convulsive  disease ;   as,  for  example,  the   re- 

'  Obstet.  Trans.,  vol.  viii. 


PUERPERAL    ECLAMPSIA.  573 

searches  of  Kassmaul  and  Tenner,  who  had  experimentally  proved 
the  dependence  of  convulsion  on  cerebral  anaemia,  and  of  Brown- 
S^quard,  who  showed  that  an  anaemic  condition  of  the  nerve-centres 
preceded  an  epileptic  attack.  It  ex])lains  also  very  satisfactorily  how 
the  occurrence  of  labor  should  intensify  the  convulsions,  since,  during 
the  acme  of  the  pains,  the  tension  of  the  cerebral  arterial  system  is 
necessarily  greatly  increased.  There  are,  however,  obvious  dil]ficul- 
ties  against  its  general  acceptance.  For  example,  it  does  not  satis- 
factorily account  for  those  cases  which  are  preceded  by  well-marked 
precursory  symptoms,  and  in  which  an  abundance  of  albumen  is 
present  in  the  urine.  Here  the  premonitory  signs  are  precisely  those 
which  precede  the  development  of  urasmia  in  chronic  Bright's  disease, 
the  dependence  of  which  on  the  retention  in  the  blood  of  urinary- 
elements  can  hardly  be  doubted. 

Views  of  MacDonald. — MacDonald'  has  published  an  interesting 
paper  on  this  subject,  in  which  he  describes  two  very  careful  post- 
mortem examinations.  In  these  he  found  extreme  anemia  of  the 
cerebro-spinal  centres,  with  congestion  of  the  meninges,  but  no  evi- 
dence of  oedema.  lie  inclines  to  the  belief  that  eclampsia  is  caused 
by  irritation  of  the  vaso- motor  centre  in  consequence  of  an  ansemic 
condition  of  the  blood,  produced  by  the  retention  in  it  of  excremen- 
titious  matters  which  the  kidneys  ought  to  have  removed,  this  over- 
stimulation resulting  in  anaemia  of  the  deeper  seated  nerve  centres 
and  consequent  convulsion. 

Excitahility  of  Nervous  System. — The  key  to  the  liability  of  the 
puerperal  woman  to  convulsive  attacks  is,  no  doubt,  to  be  found  in 
the  peculiar  excitable  condition  of  the  nervous  svstem  in  pregnancy 
— a  fact  which  was  clearly  pointed  out  by  the  late  Dr.  Tyler  Smith, 
and  by  many  other  writers.  Her  nervous  system  is,  in  this  respect, 
not  unlike  that  of  children,  in  whom  the  predominant  influence  and 
great  excitability  of  the  nervous  system  are  well-established  facts,  and 
in  whom  precisely  similar  convulsive  seizures  are  of  common  occur- 
rence on  the  application  of  a  sufficiently  exciting  cause. 

Exciting  Causes. — Admitting  this,  we  require  some  cause  to  set 
the  predisposed  nervous  system  into  morbid  action ;  and  this  we  may 
have  either  in  a  toxgemic,  or  in  an  extremely  waterj^,  condition  of 
the  blood,  associated  with  albuminuria;  or  along  with  these,  or  some- 
times independently  of  them,  in  some  excitement,  such  as  strong  emo- 
tional disturbance.  It  is  highly  probable,  however,  that  extreme 
anaemia  is  one  of  the  actual  conditions  of  the  nerve-centres — a  fact 
of  much  practical  importance  in  reference  to  treatment. 

Treatment. — ^The  management  of  cases  in  which  the  occurrence  of 
suspicious  symptoms  has  led  to  the  defection  of  albuminuria,  has  al- 
ready been  fully  discussed  (p.  199.)  We  shall,  therefore,  here  only 
consider  the  treatment  of  cases  in  which  convulsions  have  actually 
occurred. 

Venesection. — Until  quite  recently  venesection  was  regarded  as  the 

'  See  his  voL  of  Collected  Essays,  entitled  Heart  Disease  During  Pregnancy,  London, 

1878. 


574  THE    PUERPERAL    STATE. 

sheet  anchor  in  the  treatment,  and  blood  was  always  removed  copi- 
ously, and,  there  is  sufficient  reason  to  believe,  with  occasional  re- 
markable benefit.  Many  cases  are  recorded  in  which  a  patient,  in 
apparently  profound  coma,  rapidly  regained  her  consciousness  when 
blood  was  extracted  in  sufficient  quantity.  The  improvement,  how- 
ever, was  often  transient,  the  convulsions  subsequently  recurring  with 
increased  vigor.  There  are  good  theoretical  grounds  for  believing 
that  blood-letting  can  only  be  of  merely  temporary  use,  and  may 
even  increase  the  tendency  to  convulsion.  These  are  so  well  put  by 
Schroeder,  that  I  cannot  do  better  than  quote  his  observations  on 
this  point: — "If,"  he  says,  "the  theory  of  Traube  and  Rosenstein  be 
correct,  a  sudden  depletion  of  the  vascular  system,  by  which  the 
pressure  is  diminished,  must  stop  the  attacks.  From  experience  it  is 
known  that  after  venesection  the  quantity  of  blood  soon  becomes  the 
same  through  the  serum  taken  from  all  the  tissues,  while  the  quality 
is  greatly  deteriorated  by  the  abstraction  of  blood.  A  short  time 
after  venesection  we  shall  expect  to  find  the  former  blood-pressure 
in  the  arterial  system,  but  the  blood  far  more  watery  than  previously. 
From  this  theoretical  consideration,  it  follows  that  abstraction  of 
blood,  if  the  above-mentioned  conditions  really  cause  convulsions, 
must  be  attended  by  an  immediate  favorable  result,  and.  under  cer- 
tain circumstances,  the  whole  disease  may  surely  be  cut  short  by  it. 
But,  if  all  other  conditions  remain  the  same,  the  blood-pressure  will 
after  some  time  again  reach  its  former  height.  The  quantity  of  blood 
has,  in  the  mean  time,  been  greatly  deteriorated,  and  consequently 
the  danger  of  the  disease  will  be  increased." 

In  Properly -selected  Cases  Venesectioyi  is  a  Yaluahle  Remedy. — These 
views  sufficiently  well  explain  the  varying  opinions  held  with  regard 
to  this  remedy,  and  enable  us  to  understand  why,  while  the  effects 
of  venesection  have  been  so  lauded  by  certain  authors,  the  mortality 
has  admittedly  been  much  lessened  since  its  indiscriminate  use  has 
been  abandoned.  It  does  not  follow  because  a  remedy,  when  carried 
to  excess,  is  apt  to  be  hurtful,  that  it  should  be  discarded  altogether; 
and  I  have  no  doubt  that,  in  properly-selected  cases,  and  judiciously 
employed,  venesection  is  a  valuable  aid  in  the  treatment  of  eclampsia, 
and  that  it  is  specially  likely  to  be  useful  in  mitigating  the  first 
violence  of  the  attack,  and  in  giving  time  for  other  remedies  to  come 
into  action.  Care  should,  however,  be  taken  to  select  the  cases 
properly,  and  it  will  be  specially  indicated  when  there  is  marked 
evidence  of  great  cerebral  congestion  and  vascular  tension,  such  as 
a  livid  face,  a  full  bounding  pulse,  and  strong  pulsation  in  the  caro- 
tids. The  general  constitution  of  the  patient  may  also  serve  as  a 
guide  in  determining  its  use,  and  we  shall  be  the  more  disposed  to 
resort  to  it  if  the  patient  be  a  strong  and  healthy  woman  ;  while,  on 
the  other  hand,  if  she  be  feeble  and  weak,  we  may  wisely  discard  it, 
and  trust  entirely  to  other  means.  In  any  case,  it  must  be  looked 
upon  as  a  temporary  expedient  only ;  useful  in  warding  off  immediate 
danger  to  the  cerebral  tissues,  but  never  as  the  main  agent  in  treat- 
ment.    Nor  can  it  be  permissible  to  bleed  in  the  heroic  manner  fre- 


PUERPERAL    ECLAMPSIA.  575 

quentlj  recommended.     A  single  bleeding,  tlie  amount  regulated  by 
the  effect  produced,  is  all  that  is  ever  liicely  to  be  of  service. 

[After  tlie  discovery  of  the  uriemic  origin  of  eclampsia  in  pregnant 
women,  the  treatment  by  bleeding  was  very  generally  abandoned  in 
the  United  States :  but  the  more  recent  investigations  of  the  causes 
of  death  have  produced  a  reconsideration  of  this  plan  of  treatment, 
and  the  tendency  of  the  profession  during  the  last  ten  years  has  been 
towards  venesection,  as  a  preventive  of  cerebral  complications.  In 
primiparie  with  a  full  pulse  and  flushed  face,  tlie  rule  with  many  of 
our  obstetrical  practitioners  is  to  bleed  the  patient  as  early  as  prac- 
ticable, and  do  this  at  least  once  effectually,  so  as  to  produce,  if  possi- 
ble, a  noticeable  impression.  Where  there  are  positive  evidences  of 
the  existence  of  Bright's  disease,  of  course  this  is  inadmissible. — Ed.] 

Compression  of  the  Carotids. — As  a  temporary  expedient,  having 
the  same  object  in  view,  compression  of  the  carotids  during  the  par- 
oxysms is  worthy  of  trial.  This  was  proposed  by  Trousseau  in  the 
eclampsia  of  infants,  and  in  the  single  case  of  eclampsia  in  which  I 
have  tried  it  it  seemed  to  be  decidedly  beneficial.  It  is  a  simple 
measure,  and  it  offers  the  advantage  of  not  leading  to  any  permanent 
deterioration  of  the  blood,  as  in  venesection. 

Administration  of  Purgatives. — As  a  subsidiary  means  of  diminish- 
ing vascular  tension  the  administration  of  a  strong  purgative  is  de- 
sirable, and  has  the  further  effect  of  removing  any  irritant  matter 
that  may  be  lodged  in  the  intestinal  tract.  If  the  patient  be  con- 
scious a  full  dose  of  the  compound  jalap  powder  may  be  given,  or  a 
few  grains  of  calomel  combined  with  jalap ;  and  if  she  be  comatose, 
and  unable  to  swallow,  a  drop  of  croton  oil,  or  a  quarter  of  a  grain 
of  elaterium,  may  be  placed  on  the  back  of  the  tongue. 

Administration  of  Sedatives  and  Narcotics. — The  great  indication 
in  the  management  of  eclampsia  is  the  controlling  of  convulsive  action 
by  means  of  sedatives.  Foremost  amongst  them  must  be  placed  the 
inhalation  of  chloroform,  a  remedy  whicb.  is  frequently  remarkably 
useful,  and  which  has  the  advantage  of  being  applicable  at  all  stages 
of  the  disease,  and  whether  the  patient  be  comatose  or  not.  Theo- 
retical objections  have  been  raised  against  its  employment,  as  being 
likely  to  increase  cerebral  congestion  ;  of  this  there  is  no  satisfactory 
proof,-  on  the  contrary,  there  is  reason  to  think  that  chloroform 
inhalation  has  rather  the  effect  of  lessening  arterial  tension,  while 
it  certainly  controls  the  violent  muscular  action  by  which  the  hyper- 
£emia  is  so  much  increased.  Practically  no  one  who  has  used  it  can 
doubt  its  great  value  in  diminishing  the  force  and  frequency  of  the  - 
convulsive  paroxysms.  Statistically  its  usefulness  is  shown  by  Char- 
pentier,  in  his  thesis  on  the  effects  of  various  methods  of  treatment 
in  eclampsia,  since  out  of  63  cases  in  which  it  was  used,  in  48  it  had 
the  effect  of  diminishing  or  arresting  the  attacks,  1  only  proving 
fatal.  The  mode  of  administration  has  varied.  Some  have  given 
it  almost  continuously,  keeping  the  patient  in  a  more  or  less  profound 
state  of  anaesthesia.  Others  have  contented  themselves  with  care- 
fully watching  the  patient,  and  exhibiting  the  chloroform  as  soon  as 
there  were  any  indications  of  a  recurring  paroxysm,  >vith  the  view 


576  THE    PUERPERAL    STATE. 

of  controlling  its  intensity.  The  latter  is  the  plan  I  have  myself 
adopted,  and  of  the  value  of  which,  in  most  cases,  I  have  no  doubt. 
Every  now  and  again,  cases  will  occur  in  which  chloroform  inhala- 
tion is  insufficient  to  control  the  paroxysm,  or  in  which,  from  the 
very  cyanosed  state  of  the  patient,  its  administration  seems  contra- 
indicated.  Moreover,  it  is  advisable  to  have,  if  possible  some  remedy 
more  continuous  in  its  action,  and  requii^ing  less  constant  personal 
supervision.  Latterly  the  internal  administration  of  chloral  has  been 
recommended  for  this  purpose.  My  own  experience  is  decidedly  in 
its  favor,  and  I  have  used,  as  I  believe,  with  marked  advantage  a 
combination  of  chloral  with  bromide  of  potassium,  in  the  proportion 
of  twenty  grains  of  the  former  to  half  a  drachm  of  the  latter,  repeated 
at  intervals  of  from  four  to  six  hours.  If  the  jD^tient  be  unable  to 
swallow,  the  chloral  may  be  given  in  an  enema,  or  hypodermically, 
6  grains  being  diluted  in  5j  of  water,  and  injected  under  the  skin. 
The  remarkable  influence  of  bromide  of  potassium  in  controlling  the 
eclampsia  of  infants  would  seem  to  be  an  indication  for  its  use  in 
puerperal  cases.  Fordyce  Barker  is  opposed  to  the  use  of  chloral,  which 
he  thinks  excites  instead  of  lessening  reflex  irritability.'^  Another 
remedy,  not  entirely  free  from  theoretical  objections,  but  strongly 
recommended,  is  the  subcutaneous  injection  of  morphia,  which  has 
the  advantage  of  being  applicable  when  the  patient  is  quite  unable 
to  swallow.  It  may  be  given  in  doses  of  one-third  of  a  grain,  repeated 
in  a  few  hours,  so  as  to  keep  the  patient  well  under  its  influence.  It 
is  to  be  remembered  that  the  object  is  to  control  muscular  action,  so 
as  to  prevent,  as  much  as  possible,  the  violent  convulsive  paroxysm, 
and,  therefore,  it  is  necessary  that  the  narcosis,  however  produced, 
should  be  continuous.  It  is  rational,  therefore,  to  combine  the  inter- 
mittent action  of  chloroform  with  the  more  continuous  action  of  other 
remedies,  so  that  the  former  should  supplement  the  latter  when  in- 
sufficient. Pilocarpin  has  recently  been  tried  in  the  hope  that  the 
diaphoresis  and  salivation  it  produces  might  diminish  arterial  tension 
and  free  the  blood  of  toxic  matters.  Braun^  administered  3  centi- 
grammes of  the  muriate  of  pilocai'pin  hypodermically,  and  reports 
favorably  of  the  result ;  Fordyce  Barker,^  however,  is  of  opinion  that 
it  produces  so  much  depression  as  to  be  dangerous. 

Other  remedies^  supposed  to  act  in  the  way  of  antidotes  to  urc^mic 
poisoning,  have  been  advised,  such  as  acetic  or  benzoic  acid,  but 
they  are  far  too  uncertain  to  have  any  reliance  placed  on  them,  and 
they  distract  attention  from  more  useful  measures. 

Precautions  during  the  Paroxysm. — Precautions  are  necessary 
during  the  fits  to  prevent  the  patient  injuring  herself,  especially  to 
obviate  laceration  of  the  tongue ;  the  latter  can  be  best  done  by 
placing  something  between  the  teeth  as  the  paroxysm  comes  on,  such 
as  the  handle  of  a  teaspoon  enveloped  in  several  folds  of  flannel. 

Obstetric  Management. — The  obstetric  management  of  eclampsia 
will  naturally  give  rise  to  much  anxiety,  and  on  this  point  there  has 

'  The  Puerperal  Diseases,  p.  120.  2  Berlin  Klin,  Wocli.,  June  16,  1879. 

3  New  York  Med.  Rec,  March  1,  1879. 


PUERPERAL  INSANITY.  577 

been  considerable  difference  of  opinion.  On  the  one  hand,  we  have 
practitioners  v/ho  advise  the  immediate  emptying  of  the  uterus,  even 
when  labor  has  commenced ;  on  the  other,  those  who  would  leave 
the  labor  entirely  alone.  Thus  Gooch  said,  "attend  to  the  convul- 
sions, and  leave  the  labor  to  take  care  of  itself;"  and  Schroeder  says, 
"especially  no  kind  of  obstetric  manipulation  is  required  for  the 
safety  of  the  mother,"  but  he  admits,  however,  that  it  is  sometimes 
advisable  to  hasten  the  labor  to  insure  the  safety  of  the  child. 

In  cases  in  which  the  convulsions  come  on  during  labor,  the  pains 
are  often  strong  and  regular,  the  labor  progresses  satisfactorily,  and 
no  interference  is  needful.  In  others  we  cannot  but  feel  that  empty- 
ing the  uterus  would  be  decidedly  beneficial.  We  have  to  reflect, 
however,  that  any  active  interference  might,  of  itself,  prove  very  irri- 
tating, and  excite  fresh  attacks.  The  influence  of  uterine  irritation 
is  apparent,  by  the  frequency  with  which  the  paroxysms  recur  with 
the  pains.  If,  therefore,  the  os  be  undilated,  and  labor  have  not 
begun,  no  active  means  to  induce  it  should  be  adopted,  although  the 
membranes  may  be  ruptured  with  advantage,  since  that  procedure 
tends  to  no  irritation.  Forcible  dilatation  of  the  os,  and  especially 
turning  are  strongly  contra-indicated. 

The  rule  laid  down  by  Tyler  Smith  seems  that  which  is  most  ad- 
visable to  follow — that  we  should  adopt  the  course  which  seems  least 
likely  to  prove  a  source  of  irritation  to  the  mother.  Thus  if  the  fits 
seem  evidently  induced  and  kept  up  by  the  pressure  of  the  foetus, 
and  the  head  be  within  reach,  the  forceps  or  even  craniotomy  may 
be  resorted  to.  But  if,  on  the  other  hand,  there  be  reason  to  think 
that  the  operation  necessary  to  complete  delivery  is  likely  per  se  to 
prove  a  greater  source  of  irritation  than  leaving  the  case  to  nature, 
then  we  should  not  interfere. 


CHAPTEE   lY. 

PUERPERAL  li^^SANITY. 

Classification. — Under  the  head  of  ^'"Puerperal  Mania'''  writers  on 
obstetrics  have  indiscriminately  classed  all  cases  of  mental  disease 
connected  with  pregnancy  and  parturition.  The  result  has  been 
unfortunate,  for  the  distinction  between  the  various  types  of  mental 
disorder  has,  in  consequence,  been  very  generally  lost  sight  of.  But 
little  study  of  the  subject  suffices  to  show  that  the  term  Puerperal 
Mania  is  Avrong  in  more  ways  than  one,  for  we  find  that  a  large 
number  of  cases  are  not  cases  of  "  mania"  at  all,  but  of  melancholia  ; 
while  a  considerable  number  are  not,  strictly  speaking,  "  puerperal," 
as  they  either  come  on  during  pregnancy,  or  long  after  the  immediate 


578  THE    PUERPERAL    STATE. 

risks  of  the  puerperal  period  are  over,  being  in  the  latter  case  asso- 
ciated with  anaemia  produced  by  over-lactation.  For  the  sake  of 
brevity,  the  generic  term  '■'•  Puer-peral  Insanity''^  may  be  emploj^ed  to 
cover  all  cases  of  mental  disorders  connected  with  gestation,  which 
may  be  further  conveniently  subdivided  into  three  classes,  each 
having  its  special  characteristics,  viz. : — 

I.  The  Insanity  of  Pregnancy. 

II.  Puerperal  Insanity^  properly  so  called,  that  is  insanity  coming 
on  within  a  limited  period  after  delivery. 

III.  The  Insanity  of  Lactation. 

This  division  is  a  strictly  natural  one,  and  includes  all  the  cases 
likely  to  come  under  observation.  The  relative  proportion  these 
classes  bear  to  each  other  can  only  be  determined  by  accurate  statis- 
tical observations  on  a  large  scale,  but  these  materials  we  do  not 
possess.  The  returns  from  large  asylums  are  obviously  open  to  ob- 
jection, for  only  the  worst  and  most  confirmed  cases  find  their  way 
into  these  institutions,  while  by  far  the  greater  proportion,  both 
before  and  after  labor,  are  treated  in  their  own  homes. 

Taking  such  returns  as  only  approximate,  we  find  from  Dr.  Batty 
Tuke^  that  in  the  Edinburgh  Asylum  out  of  105  cases  of  puerperal 
insanity,  28  occurred  before  delivery,  13  during  the  puerperal  period, 
and  51  during  lactation.  The  relative  proportions  of  each  per  hun- 
dred are  as  follows  : — 

Insanity  of  Pregnancy,  18.06  per  cent. 
Puerperal  Insanity,         47.09       " 
Insanity  of  Lactation,    34.08        " 

Marce^  collects  together  several  series  of  cases  from  various  authori- 
ties, amounting  to  310  in  all,  and  the  results  are  not  very  different  from 
those  of  the  Edinburgh  Asylum,  except  in  the  relatively  smaller 
number  of  cases  occurring  before  delivery.  The  percentage  is  cal- 
culated from  his  fissures: — • 

Insanity  of  Pregnancy,  8,06  per  cent. 
Puerperal  Insanity,      58.06         " 
Insanity  of  Lactation,  30.30         " 

As  each,  of  these  classes  differs  in  various  important  respects  from 
the  others,  it  will  be  better  to  consider  each  separately. 

Insanity  of  Pregnancy. — The  Insanity  of  Pregnancy  is,  without 
doubt,  the  least  common  of  the  three  forms.  The  intense  mental 
depression  which  in  many  women  accompanies  pregnancy,  and  causes 
the  jjatient  to  take  a  desponding  view  of  her  condition,  and  to  look 
forward  to  the  result  of  her  labor  with  the  most  gloomy  apprehen- 
sion, seems  to  be  often  only  a  lesser  degree  of  the  actual  mental 
derangement  which  is  occasionally  met  with.  The  relation  between 
the  two  states  is  further  borne  out  by  the  fact  that  a  large  majority 
of  cases  of  insanity    during  pregnancy  are    well-marked  types  of 

'  Edin.  Med  Journ.,  vol.  x. 

2  Traite  de  la  Folie  des  Femmes  enceintes. 


PUERPERAL  INSANITY.  679 

melancholia ;  out  of  28  cases,  reported  by  Tuke,  15  were  examples 
of  pure  melancholia,  5  of  dementia  with  melancholia.  In  many  of 
these  the  attack  could  be  traced  as  developing  itself  out  of  the  ordi- 
nary hypochondriasis  of  pregnancy.  In  others  the  symptoms  came 
on  at  a  later  period  of  pregnancy,  the  earlier  months  of  which  had 
not  been  marked  by  any  unusual  lowness  of  spirits.  The  age  of  the 
patient  seems  to  have  some  influence,  the  proportion  of  cases  between 
30  and  40  years  of  age  being  much  larger  tkan  in  younger  women. 
A  larger  proportion  of  cases  occur  in  primiparae  than  in  multiparas, 
a  fact  that,  no  doubt,  depends  on  the  greater  dread  and  apprehension 
experienced  by  women  who  are  pregnant  for  the  first  time,  especially 
if  not  very  young.  Hereditary  disposition  plays  an  important  part, 
as  in  all  Ibrms  of  puerperal  insanity.  It  is  not  always  easy  to  ascer- 
tain the  fact  of  an  hereditary  taint,  since  it  is  often  studiously  con- 
cealed by  the  friends.  Tuke,  however,  found  distinct  evidence  of  it 
in  no  less  than  12  out  of  28  cases.  Fiirstner*  believes  that  other  neu- 
roses have  an  important  influence  in  the  causation  of  the  disease. 
Out  of  32  cases  he  found  direct  hereditary  taint  in  9,  but  in  11  more 
there  was  a  family  history  of  epilepsy,  drunlcenness  or  hysteria. 

Period  of  Prey  nancy  ativhich  it  Occurs. — The  period  of  pregnancy, 
at  which  mental  derangement  most  comraonl}^  shows  itself  varies. 
Most  generally,  perhaps,  it  is  at  the  end  of  the  third,  or  the  beginning 
of  the  fourth  month.  It  may  however,  begin  with  conception,  and 
even  return  with  every  impregnation.  Montgomery  relates  an  in- 
stance in  which  it  reciirred  in  three  successive  pregnancies.  Marce 
distinguishes  between  true  insanity  coming  on  during  pregnancy 
and  aggravated  hypochondriasis,  by  the  fact  that  the  latter  usually 
lessens  after  the  third  month,  while  the  former  most  commonly  only 
begins  after  that  date.  It  is  unquestionable  that  in  many  cases  no 
such  distinction  can  be  made,  and  that  the  two  are  often  very  inti- 
mately associated. 

Form  of  Insanity. — ^The  form  of  insanity  does  not  differ  from  ordi- 
nary melancholia.  The  suicidal  tendency  is  generally  \erj  strongly 
developed.  Should  the  mental  disorder  continue  after  delivery,  the 
patient  may  very  probably  experience  a  strong  impulse  to  kill  her 
child.  Moral  perversions  have  been  not  uncommonly  observed. 
Tuke  especially  mentions  a  tendency  to  dipsomania  in  the  early 
months,  even  in  women  who  have  not  shown  any  disposition  to 
excess  at  other  times.  He  suggests  that  this  may  be  an  exaggeration 
of  the  depraved  appetite,  or  morbid  craving,  so  commonly  observed 
in  pregnant  women,  just  as  melancholia  may  be  a  further  develop- 
ment of  lowness  of  spirits.  Laycock  mentions  a  disposition  to  "  klep- 
tomania" as  very  characteristic  of  the  disease.  Casper^  relates  a 
curious  case  where  this  occurred  in  a  pregnant  lady  of  rank,  and  the 
influence  of  pregnancy,  in  developing  an  irresistible  tendency,  was 
pleaded  in  a  criminal  trial  in  which  one  of  her  petty  thefts  had 
involved  her. 

'  Arcliiv.  fur  Psycliiatrie,  Band  v.  Heft  2. 
2  Casper's  Forensic  Medicine,  vol.  iv. 


580  THE    PUERPERAL    STATE. 

Prognosis. — The  prognosis  may  be  said  to  be,  on  the  whole,  favor- 
able. Out  of  Dr.  Take's  28  cases,  19  recovered  within  six  months. 
There  is  little  hope  of  a  cure  until  after  the  termination  of  the  preg- 
nancy, as  out  of  19  cases  recorded  by  Marce  only  in  2  did  the  insanity 
disappear  before  delivery. 

Transient  Mania  during  Delivery. — There  is  a  peculiar  form  of 
mental  derangement  sometimes  observed  during  labor,  wliich  is  by 
some  talked  of  as  a  temporarj^  insanity.  It  may,  perhaps,  be  more 
accurately  described  as  a  kind  of  acute  delirium,  produced,  in  the 
latter  stage  of  labor,  by  the  intensity  of  the  suffering  caused  by  the 
pains.  According  to  Montgomery,  it  is  most  apt  to  occur  as  the  head 
is  passing  through  the  os  uteri,  or,  at  a  later  period,  during  the  ex- 
pulsion of  the  child.  It  may  consist  of  merely  a  loss  of  control  over 
the  mind,  during  which  the  patient,  unless  carefully  watched,  might, 
in  her  agony,  seriously  injure  herself  or  her  child.  Sometimes  it 
produces  actual  hallucination,  as  in  the  case  described  by  Tarnier, 
in  which  the  patient  fancied  she  saw  a  spectre  standing  at  the  foot 
of  her  bed,  which  she  made  violent  efltbrts  to  drive  away.  This  kind 
of  mania,  if  it  may  be  so  called,  is  merely  transitory  in  its  character, 
and  disappears  as  soon  as  the  labor  is  over.  From  a  medico-legal 
point  of  view  it  may  be  of  importance,  as  it  has  been  held  by  some 
that  in  certain  cases  of  infanticide  the  mother  has  destroyed  the  child 
when  in  this  state  of  transient  frenzy,  and  when  she  was  irrespon- 
sible for  her  acts.  In  the  treatment  of  this  varietj''  of  delirium  we 
must,  of  course,  try  to  lessen  the  intensity  of  the  suffering,  and  it  is 
in  such  cases  that  chloroform  will  find  one  of  its  most  valuable 
applications. 

Pueri-jeral  Insanity  (prope}').- — ^True  puerperal  insanity  has  always 
attracted  much  attention  from  obstetricians,  often  to  the  exclusion  of 
other  forms  of  mental  disturbance  connected  with  the  puerperal 
state.  We  may  define  it  to  be,  that  form  of  insanity  which  comes 
on  within  a  limited  period  after  delivery,  and  which  is  probably  in- 
timately connected  with  that  process.  Out  of  73  examples  of  the 
disease  tabulated  by  Dr.  Tuke,  only  2  came  on  later  than  a  month 
after  delivery,  and  in  these  there  were  other  causes  present,  which 
might  possibly  remove  them  from  this  class. 

Although  a  large  number  of  these  cases  assume  the  character  of 
acute  mania,  that  is  by  no  means  the  only  kind  of  insanity  which  is 
observed,  a  not  inconsiderable  number  being  well  marked  examples 
of  melancholia.  The  distinction  between  them  was  long  ago  pointed 
out  by  Gooch,  whose  admirable  monograph  on  the  disease  contains 
one  of  the  most  graphic  and  accurate  accounts  of  puerperal  insanity 
that  has  yet  been  written. 

There  are  also  some  peculiarities  as  to  the  period  at  which  these 
varieties  of  insanity  show  themselves,  which,  taken  in  connection 
with  certain  facts  in  their  etiology,  may  eventually  justify  us  m 
drawing  a  stronger  line  of  demarcation  between  them  than  has  been 
usual.  It  appears  that  cases  of  acute  mania  are  apt  to  come  on  at  a 
period  much  nearer  delivery  than  melancholia.  Thus  Tuke  found 
that  all  the  cases  of  mania  came  on  within  sixteen  days  after  delivery, 


PUERPERAL  INSANITY.  581 

and  tliat  all  cases  of  melancliolia  developed  themselves  after  that 
period.  We  shall  presently  see  that  one  of  the  most  recent  theories 
as  to  the  causation  of  the  disease  attributes  it  to  some  morbid  condi- 
tion of  the  blood.  Should  further  investigation  conilrm  this  supposi- 
tion inasmuch  as  septic  conditions  of  the  blood  are  most  likely  to 
occur  a  short  time  after  labor,  it  would  not  be  an  improbable  hy- 
pothesis that  cases  of  acute  mania,  occurring  within  a  short  time 
after  labor,  may  depend  on  such  septic  causes,  while  melancholia  is 
more  likely  to  arise  from  general  conditions  favoring  the  develop- 
ment of  mental  disease.  This  must,  however,  be  regarded  as  a  mere 
speculation  requiring  further  investigation. 

Causes. — flereditary  predisposition  is  very  frequently  met  with, 
and  a  careful  inquiry  into  the  patient's  history  will  generally  show- 
that  other  members  of  the  family  have  suffered  from  mental  derange- 
ment. Esid  found  that  out  of  111  cases  in  Bethlehem  Hospital  there 
was  clear  evidence  of  hereditary  taint  in  45.  Tuke  made  the  same 
observation  in  22  out  of  his  73  cases ;  and,  indeed,  it  is  pretty  gene- 
rally admitted  by  all  alienist  physicians  that  hereditary  tendencies 
form  one  of  the  strongest  predisposing  causes  of  mental  disturbance 
in  the  puerperal  state.  In  a  larga  proportion  of  cases  circumstances 
producing  debility  and  exhaustion,  or  mental  depression,  have  pre- 
ceded the  attack.  Tiius  it  is  often  found  that  patients  attacked  with 
it  have  had  post-partum.  hemorrhage,  or  have  suffered  from  some 
other  conditions  producing  exhaustion,  such  as  severe  and  complicated 
labor  ;  or  they  may  have  been  weakened  by  over-frequent  pregnan- 
cies, or  by  lactation  during  the  early  months  of  pregnancy.  Indeed 
anaemia  is  always  well  marked  in  this  disease.  Mental  conditions 
also  are  frequently  traceable  in  connection  with  its  production.  Mor- 
bid dread  during  pregnancy,  insufficient  to  ])roduce  insanity  before 
delivery,  may  develop  into  mental  derangement  after  it.  Shame  and 
fear  of  exposure  in  unmarried  women  not  unfrequently  lead  to  it,  as 
is  evidenced  by  the  fact  that  out  of  2281  cases,  gathered  from  the 
reports  of  various  asylums,  above  64  per  cent,  were  unmarried.^ 
Sudden  moral  shocks  or  vivid  mental  impressions  may  be  the  deter- 
mining cause  in  predisposed  persons.  Gooch  narrates  an  example  of 
this  in  a  lady  who  was  attacked  immediately  after  a  fright  produced 
by  a  fire  close  to  her  house,  the  hallucinations  in  this  case  being  all 
connected  with  light ;  and  Tyler  Smith  that  of  another  whose  ill- 
ness dated  from  the  sudden  death  of  a  relative.  The  age  of  the  patient 
has  some  influence,  and  there  seems  to  be  a  decidedl}^  greater  liability 
at  advanced  ages,  especially  when  such  women  are  pregnant  for  the 
first  time. 

Theory  of  its  Dependence  on  Morhid  State  of  the  Blood. — The  possi- 
bility of  the  acute  form  of  puerperal  insanity,  coming  on  shortly 
after  delivery,  being  dependent  on  some  form  of  septicasmia  is  one 
which  deserves  careful  consideration.  The  idea  originated  with  Sir 
James  Simpson,  who  found  albumen  in  the  urine  of  4  patients.  He 
suggested  that  this  might  probably  indicate  the  presence  in  the  blood 

1  Journ.  of  Mental  Science,  1870-1,  p.  159. 


682  THE    PUERPERAL    STATE. 

of  certain  urinarj  constituents,  wliicli  might  have  determined  the 
attaciv,  mucli  in  the  same  way  as  in  eclampsia.  Dr.  Donl^in  subse- 
quently wrote  an  important  paper/  in  which  he  warmlj^  supported 
tnis  theory,  and  arrived  at  the  conclusion,  "  that  the  acute  dangerous 
class  of  cases  are  examples  of  urasmic  blood-poisoning,  of  which  the 
mania,  rapid  pulse,  and  other  constitutional  symptoms  are  merely 
the  phenomena ;  and  that  the  affection,  therefore,  ought  to  be  termed 
urasmic  or  renal  puerperal  mania,  in  contradistinction  to  the  other 
form  of  the  disease."  Pie  also  suggests  that  the  immediate  poison 
may  be  carbonate  of  ammonia,  resulting  from  the  decomposition  of 
urea  retained  in  the  blood.  It  will  be  observed,  therefore,  that  the 
pathological  condition  producing  puerperal  mania  would,  supposing 
this  theory  to  be  correct,  be  precisely  the  same  as  that  which,  at 
other  times,  is  supposed  to  give  rise  to  puerperal  eclampsia.  There 
can  be  no  doubt  that  the  patient,  immediately  after  delivery,  is  in  a 
condition  rendering  her  peculiarly  liable  to  various  forms  of  septic 
disease  ;  and  it  must  be  admitted  that  there  is  no  inherent  improba- 
bility in  the  supposition  that  some  moibid  material  circulating  in  the 
blood  may  be  the  effective  cause  of  the  attack,  in  a  person  otherwise 
predisposed  to  it.  It  is  also  certain,  as  I  have  already  pointed  out, 
that  there  are  two  distinct  classes  of  cases,  differing  according  to  the 
period  after  delivery  at  which  the  attack  comes  on.  Whether  this 
difference  depends  on  the  presence  in  the  blood  of  some  septic  mat- 
ter— especially  urinary  excreta — is  a  question  which  our  knowledge 
by  no  means  justifies  us  in  answering;  it  is,  however,  one  which  well 
merits  further  careful  study. 

Objections  to  this  Theory. — It  is  only  fair  to  point  out  some  difficul- 
ties which  appear  to  militate  against  the  view  which  Dr.  Donkin 
maintains.  In  the  first  place,  the  albuminuria  is  merely  transient, 
while  its  supposed  effects  last  for  weeks  or  months.  Sir  James 
Simpson  says,  with  regard  to  his  cases :  "  I  have  seen  all  traces  of 
albuminuria  in  puerperal  insanity  disappear  from  the  urine  within 
fifty  hours  of  the  access  of  the  malady.  The  general  rapidity  of  its 
disappearance  is,  perhaps,  the  principal,  or,  indeed,  the  only  reason 
why  this  complication  has  escaped  the  notice  of  those  physicians 
among  us  who  devote  themselves  with  such  ardor  and  zeal  to  the 
treatment  of  insanity  in  our  public  asylums."  This  apparent  anomaly 
Simpson  attempts  to  explain  by  the  hypothesis  that,  when  once  the 
urasmic  poisoning  has  done  its  work,  and  set  the  disease  in  progress, 
the  mania  progresses  of  itself.  This,  however,  is  pure  speculation  ; 
and,  in  the  supposed  analogous  case  of  eclampsia,  the  albuminuria 
certainly  lasts  as  long  as  its  effects.  It  is  not  easy  to  understand, 
also,  why  uraemic  poisoning  should  in  one  case  give  rise  to  insanity, 
and  in  another  to  convulsions.  For  all  we  know  to  the  contrary, 
transient  albuminuria  may  be  much  more  common  after  delivery  than 
has  been  generally  supposed,  and  further  investigation  on  this  point 
is  required.  Albumen  is  by  no  means  unfrequently  observed  in  the 
urine,  for  a  short  time,  in  various  conditions  of  the  body,  without 

^  Edin.  Med.  Journ.,  vol.  vii. 


PUERPERAL  INSANITY.  583 

any  serious  consequences,  as,  for  example,  after  bathing :  and  we 
may  too  readily  draw  an  unjustifiable  conclusion  from  its  detection 
in  a  few  cases  of  mania.  There  are,  however,  many  other  kinds  of 
blood-poisoning,  besides  urtemia,  which  may  have  an  influence  in  the 
production  of  the  disease,  and  it  is  to  be  hoped  that  future  observa- 
tions may  enable  us  to  speak  with  more  certainty  on  this  point. 

Prognosis. — The  prognosis  of  puerperal  insanity  is  a  point  which 
will  always  deeply  interest  those  who  have  to  deal  with  so  distress- 
ing a  malady.  It  may  resolve  itself  into  a  consideration  of  the  im- 
mediate risk  to  life,  and  of  the  chances  of  ultimate  restoration  of  the 
mental  faculties.  It  is  an  old  aphorism  of  Grooch's,  and  one  the 
correctness  of  which  is  justified  by  modern  experience,  that  "  mania 
is  more  dangerous  to  life,  melancholia  to  reason."  It  has  yqtj  gene- 
rally been  supposed  that  the  immediate  risk  to  life  in  puerperal 
mania  is  not  great,  and,  on  the  whole,  this  may  be  taken  as  correct. 
Tuke  found  that  death  took  place,  from  all  causes,  in  10.9  of  the 
cases  under  observation ;  these,  however,  were  all  women  who  had 
been  admitted  into  asylums,  and  in  whom  the  attack  mav  be  assumed 
to  have  been  exceptionally  severe.  Great  stress  was  laid  by  Hunter 
and  Gooch  on  extreme  rapidity  of  the  pulse,  as  indicating  a  fatal 
tendency.  There  can  be  no  doubt  that  it  is  a  symptom  of  great 
gravity,  but  by  no  means  one  which  need  lead  us  to  despair  of  our 
patient's  recovery.  The  most  dangerous  class  of  cases  are  those  at- 
tended with  some  inflammatory  complication  ;  and  if  there  be  marked 
elevation  of  temperature,  indicating  the  presence  of  some  such  con- 
comitant state,  our  prognosis  must  be  more  grave  than  when  there  is 
mere  excitement  of  the  circulation. 

Post-mortem  Signs. — There  are  no  marked  post-mortem  signs  found 
in  fatal  cases  to  guide  us  in  forming  an  opinion  as  to  the  nature  of 
the  disease.  "  No  constant  morbid  changes,"  says  Tyler  Smith,  "  are 
found  within  the  head,  and  most  frequently  the  only  condition  found 
in  the  brain  is  that  of  unusual  paleness  and  exsanguinitv.  Many 
jDathologists  have  also  remarked  upon  the  extremely  empty  condition 
of  the  bloodvessels,  particularly  the  veins." 

Duration  of  the  Disease. — The  duration  of  the  disease  varies  con- 
siderably. Generally  speaking,  cases  of  mania  do  not  last  so  long  as 
melancholia,  and  recovery  takes  place  Avithin  a  period  of  three 
months,  often  earlier,  Yery  few  of  the  cases  admitted  into  the 
Edinburgh  Asylum  remained  there  more  than  six  months,  and  after 
that  time  the  chances  of  ultimate  recovery  greatly  lessened.  When 
the  patient  gets  well,  it  often  happens  that  her  recollection  of  the 
events  occurring  during  her  illness  is  lost ;  at  other  times,  the  delu- 
sions from  which  she  suffered  remain,  as,  for  example,  in  a  case 
whicli  was  under  my  care,  in  which  the  personal  antipathies  which 
the  patient  formed  when  insane  became  permanently  established. 

Insanity  of  Lactation. — 54:  out  of  the  155  cases  collected  by  Dr. 
Tuke  Avere  examples  of  the  insanity  of  lactation,  which  would  appear, 
therefore,  to  be  nearly  twice  as  common  as  that  of  pregnancy,  but 
considerably  less  so  than  the  true  puerperal  form.  Its  dependence 
on  causes  producing  antemia  and  exhaustion  is  obvious  and  well 


584  THE    PUERPERAL    STATE. 

marked.  In  tlie  large  majority  of  cases  it  occurs  in  multiparse  who 
have  been  debilitated  by  frequent  pregnancies,  and  by  length  of 
nursing.  When  occurring  in  priniiparoe,  it  is  generally  in  women 
who  have  suffered  from  post-partum  hemorrhage,  or  other  causes  of 
exhaustion,  or  whose  constitution  was  such  as  should  have  contra- 
indicated  any  attempt  at  lactation.  The  bruit-de-diable  is  almost 
invariably  present  in  the  veins  of  the  neck,  indicating  the  im- 
poverished condition  of  the  blood. 

The  type  is  far  more  frequently  melancholic  than  maniacal,  and 
when  the  latter  form  occurs,  the  attack  is  much  more  transient  than 
in  true  puerperal  insanity.  The  danger  to  life  is  not  great,  especially 
if  the  cause  producing  debility  be  recognized  and  at  once  removed. 

There  seems,  however,  to  be  more  risk  of  the  insanity  becoming 
permanent  than  in  the  other  forms.  In  12  out  of  Dr.  Tuke's  cases 
the  melancholia  degenerated  into  dementia,  and  the  patient  became 
hopelessly  insane. 

Symptoms.. — The  symptoms  of  these  various  forms  of  insanity  are 
practically  the  same  as  in  the  non-pregnant  state. 

Generally  in  cases  of  mania  there  is  more  or  less  premonitory  in- 
dication of  mental  disturbance,  which  may  pass  unperceived.  The 
attack  is  often  preceded  by  restlessness  and  loss  of  sleep,  the  latter 
being  a  very  common  and  well-marked  symptom  ;  or,  if  the  patient 
do  sleep,  her  rest  is  broken  and  disturbed  by  dreams.  Causeless 
dislikes  to  those  around  her  are  often  observed ;  the  nurse,  the  hus- 
band, the  doctor,  or  the  child,  becomes  the  object  of  suspicion,  and, 
unless  proper  care  be  taken,  the  child  maybe  seriously  injured.  As 
the  disease  advances,  the  patient  becomes  incoherent  and  I'ambling 
in  her  talk,  and,  in  a  fully-developed  case,  she  is  incessantly  pouring 
forth  an  unconnected  jumble  of  sentences,  out  of  which  no  meaning 
can  be  made.  Often  some  prevalent  idea  which  is  dwelling  in  the 
patient's  mind  can  be  traced  running  through  her  ravings,  and  it  has 
been  noticed  that  this  is  frequently  of  a  sexual  character,  causing 
women  of  unblemished  reputation  to  use  obscene  and  disgusting  lan- 
guage, which  it  is  difficult  to  understand  their  even  having  heard. 
The  tendency  of  such  patients  to  make  accusations  impugning  their 
own  chastity  was  specially  insisted  on  by  many  eminent  authorities 
in  a  recent  celebrated  trial,  when  Sir  James  Simpson  stated  that  in 
his  experience  "the  organ  diseased  gave  a  type  to  the  insanity,  so 
that  with  women  suffering  from  affections  of  the  genital  organs  the 
delusions  would  be  more  likely  to  be  connected  with  sexual  matters." 
Eeligious  delusions,  as  a  fear  of  eternal  damnation,  or  of  having 
committed  some  unpardonable  sin,  are  of  frequent  occurrence,  but 
perhaps  more  often  in  cases  which  are  tending  to  the  melancholic 
type.  There  is  generally  intolerable  restlessness,  and  the  patient's 
whole  manner  and  appearance  are  those  of  excessive  excitement. 
She  may  refuse  to  remain  in  bed,  may  tear  off  her  clothes,  or  at- 
tempt to  injure  herself.  The  suicidal  tendency  is  often  very  marked. 
In  one  case  under  my  care,  the  patient  made  incessant  efforts  to 
destroy  hersslf,  which  were  only  frustrated  by  the  most  careful  watch 
ing ;  she  endeavored  to  strangle  herself  with  the  bedclothes,  to  swal- 


PUERPERAL  INSANITY.  585 

low  any  article  she  could  lay  hold  of,  and  even  to  gouge  out  her  own 
eyes.  P\x)d  is  generally  persistently  refused,  and  the  utmost  coaxing 
may  fail  in  inducing  the  patient  to  take  nourishment.  The  pulse  is 
rapid  and  small,  and  the  more  violent  the  excitement  and  furious 
the  delirium,  the  more  excited  is  the  circulation.  The  tongue  is 
coated  and  furred,  the  bowels  constipated  and  disordered,  and  the 
feces,  as  well  as  the  urine,  are  frequently  passed  involuntarily.  The 
urine  is  scanty  and  high  colored,  and,  after  the  disease  has  lasted 
for  some  time,  it  becomes  loaded  with  phospliates.  The  lochia,  and 
the  secretion  of  milk,  generally  become  arrested  at  the  commence- 
ment of  the  disease.  The  waste  of  tissue,  from  the  incessant  rest- 
lessness and  movement  of  the  patient,  is  very  great;  and,  if  the 
disease  continue  for  some  time,  she  falls  into  a  condition  of  marasmus, 
which  may  be  so  excessive,  that  she  becomes  wasted  to  a  shadow  of 
her  former  size. 

/Symptoms  of  Melancholia. — When  the  insanity  assumes  the  form 
of  melancholia,  its  advent  is  more  gradual.  It  may  commence  with 
depression  of  spirits,  without  any  adequate  cause,  associated  with  in- 
somnia, disturbed  digestion,  headache,  and  other  indications  of  bodily 
derangement.  Such  symptoms,  showing  themselves  in  women  who 
have  been  nursing  for  a  length  of  time,  or  in  whom  any  other  evident 
cause  of  exhaustion  exists,  should  never  pass  unnoticed.  Soon  the 
signs  of  mental  depression  increase,  and  positive  delusions  show  them- 
selves. These  may  vary  much  in  their  amount,  but  they  are  all  more 
or  less  of  the  same  type,  and  very  often  of  a  religious  character.  The 
amount  of  constitutional  disturbance  varies  much.  In  some  cases 
which  approach  in  character  those  of  mania,  there  is  considerable 
excitement,  rapid  pulse,  furred  tongue,  and  restlessness.  Probably 
cases  of  acute  melancholia,  coming  on  during  the  puerperal  state, 
most  often  assume  this  form.  In  others  again  there  is  less  of  these 
general  symptoms,  the  patients  are  profoundly  dejected,  sit  for  hours 
without  speaking  or  moving  ;  but  there  is  not  much  excitement,  and 
this  is  the  form  most  generally  characterizing  the  insanity  of  lacta- 
tion. In  all  cases  there  is  a  marked  disinclination  to  food.  There 
is  also,  almost  invariably,  a  disposition  to  suicide;  and  it  should 
never  be  forgotten  in  melancholic  cases  that  this  may  develop  itself 
in  an  instant,  and  that  a  moment's  carelessness  on  the^  part  of  the  at- 
tendants may  lead  to  disastrous  results. 

2\eatme7it. — Bearing  in  mind  what  has  been  said  of  the  essential 
character  of  puerperal  insanity,  it  is  obvious  that  the  course  of  treat- 
ment must  be  mainly  directed  to  maintain  the  strength  of  the  patient, 
so  as  to  enable  her  to  pass  through  the  disease  without  fatal  exhaus- 
tion of  the  vital  powers,  while  we  endeavor,  at  the  same  time,  to  calm 
the  excitement,  and  give  rest  to  the  disturbed  brain.  Any  over- 
active measures — for  example,  bleeding,  blistering  the  shaven  scalp, 
and  the  like — are  distinctly  contra-indicated. 

There  is  a  general  agreement  on  the  part  of  the  alienist  physicians 
that  in  cases  of  aaute  mania  the  two  things  most  needful  are  a  suffi- 
cient quantity  of  suitable  food  and  sleep, 
38 


586  THE    PUERPERAL    STATE. 

Importance  of  Administering  Nourishment. — -Every  endeavor  should 
be  made  to  induce  the  patient  to  talce  abundance  of  nourishment,  to 
remedy  the  effects  of  the  excessive  waste  of  tissue,  and  support  her 
strength  until  the  disease  abates.  Dr.  Blandford,  who  has  especially 
insisted  on  the  importance  of  this,  says,^  "Now,  with  regard  to  the 
food,  skilful  attendants  will  coax  a  patient  into  taking  a  large  quan- 
tity, and  we  can  hardly  give  too  much.  Messes  of  minced  meat  with 
potato  and  greens,  diluted  with  beef-tea,  bread  and  milk,  rum  and 
milk,  arrowroot,  and  so  on,  may  be  got  down.  Never  give  mere 
liquids  so  long  as  you  can  get  down  solids.  As  the  malady  pro- 
gresses, the  tongue  and  mouth  may  become  so  dry  and  foul  that 
nothing  but  liquids  can  be  swallowed;  but,  reserving  our  beef-tea 
and  brandy,  let  us  give  plenty  of  solid  food  while  we  can." 

Forcible  Administratio7i  of  Food. — The  patient  may  in  mania,  as 
well  as  in  melancholia,  perhaps  even  more  in  the  latter,  obstinately 
refuse  to  take  nourishment  at  all,  and  we  may  be  compelled  to  use 
force.  Various  contrivances  have  been  employed  for  this  purpose. 
One  of  the  simplest  is  introducing  a  dessert-spoon  forcibly  between 
the  teeth,  the  patient  being  controlled  by  an  adequate  number  of 
attendants,  and  slowly  injecting  into  the  mouth  suitable  nourishment, 
by  an  india-rubber  bottle  with  an  ivory  nozzle,  such  as  is  sold  by  all 
chemists.  Care  must  be  taken  not  to  inject  more  than  an  ounce  at 
a  time,  and  to  allow  the  patient  to  breathe  between  each  deglutition. 
So  extreme  a  measure  will  seldom  be  required,  if  the  patient  have 
experienced  attendants,  who  can  overcome  her  resistance  to  food  by 
gentler  means ;  but  it  may  be  essential,  and  it  is  far  better  to  employ 
it  than  to  allow  the  patient  to  become  exhausted  from  want  of  nour- 
ishment. In  one  case  I  had  to  feed  a  patient  in  this  way  three  times 
a  day  for  several  weeks,  and  used  for  the  purpose  a  contrivance 
known  in  asylums  as  Paley's  feeding-bottle,  which  reduced  the  diffi- 
culty of  the  process  to  a  minimum.  Beef- tea,  or  strong  soup,  mixed 
with  some  farinaceous  material,  such  as  Eevalenta  Arabica,  or  wheaten 
flour,  or  milk,  forms  the  best  mess  for  this  purpose. 

Stimulatits. — In  the  early  stages  the  patient  is  probably  better 
without  stimulants,  which  seem  only  to  increase  the  excitement.  As 
the  disease  progresses,  and  exhaustion  becomes  marked,  it  may  be 
necessary  to  have  recourse  to  them.  In  melancholia  they  seem  to  be 
more  useful,  and  may  be  administered  with  greater  freedom. 

State  of  the  Botveh. — The  state  of  the  bowels  requires  especial 
attention.  They  are  almost  alwavs  disordered,  the  evacuations 
being  dark  and  offensive  in  odor.  In  the  early  stages  of  the  disease 
the  prompt  clearing  of  the  bowels,  by  a  suitable  purgative,  some- 
times has  the  effect  of  cutting  short  an  impending  attack.  A  curious 
example  of  this  is  recorded  by  Gooch,  in  which  the  patient's  re- 
covery seemed  to  date  from  the  free  evacuation  of  the  bowels.  A 
few  grains  of  calomel,  or  a  dose  of  compound  jalap  powder,  or  of 
castor  oil,  may  generally  be  readily  given.  During  the  continuance 
of  the  illness  the  state  of  the  primae  viae  should  be  attended  to,  and 

'  Blandford,  Insanity  and  its  Treatment. 


PUERPERAL  INSANITY.  587 

occasional  aperients  will  be  useful,  but  strong  and  repeated  purga- 
tion is  hurtful  from  the  debility  it  produces. 

Tlie  j)TOcurin<j  sleep  will  necessarily  form  one  of  the  most  import- 
ant points  of  treatment.  For  this  purpose  there  is  no  drug  so  valu- 
able as  the  hydrate  of  chloral,  either  alone,  or  in  combination  with 
bromide  of  potassium,  which  has  a  distinct  effect  in  increasing  its 
hypnotic  action.  Given  in  a  full  dose  at  bedtime,  say  15  grs.  to  3ss, 
it  rarely  fails  in  procuring  at  least  some  sleep,  and,  in  an  early  stage 
of  acute  mania,  this  may  be  followed  by  the  best  eff'ects.  It  may  l)e 
necessary  to  repeat  this  draught  night  after  night,  during  the  acute 
stage  of  the  malady.  If  we  cannot  induce  the  patient  to  swallow 
the  medicine,  it  may  be  given  in  the  form  of  enema. 

Question  of  AdiidnisLeriw]  Opiates. — It  is  generall}'  admitted  that 
in  mania  preparations  of  opium,  formerly  much  relied  on  in  the 
treatment  of  the  disease,  are  apt  to  do  more  harm  than  good.  Dr. 
Blandford  gives  a  strong  opinion  onthis  point.  He  says:  "In  pro- 
longed delirious  mania  I  believe  opium  never  does  good,  and  may  do 
great  harm.  AVe  shall  see  the  effects  of  narcotic  poisoning  if  it  be 
pushed,  but  none  that  are  beneficial.  This  applies  equally  to  opium 
given  by  the  mouth  and  by  subcutaneous  injection.  The  latter,  as 
it  is  more  certain  and  effectual  in  producing  good  results,  is  also  more 
deadly  when  it  acts  as  a  narcotic  poison.  After  the  administration 
of  a  dose  of  morphia  by  the  subcutaneous  method,  the  patient  will 
probably  at  once  fall  asleep,  and  we  congratulate  ourselves  that  our 
long  wished-for  object  is  attained.  But  after  half  an  hour  or  so  the 
sleep  suddenly  terminates,  and  the  mania  and  excitement  are  worse 
than  before.  Here  you  may  possibly  think  that  had  the  dose  been 
larger,  instead  of  half  an  hour's  sleep  you  would  have  obtained  one 
of  longer  duration,  and  you  may  administer  more,  but  with  a  like 
result.  Large  doses  of  morphia  not  merely  fail  to  produce  refreshing 
sleep;  they  poison  the  patient,  and  produce,  if  not  the  symptoms  of 
actual  narcotic  poisoning,  at  any  rate  that  typhoid  condition  which 
indicates  prostration  and  approaching  collapse.  I  believe  there  is 
no  drug,  the  use  of  which  more  often  becomes  abused,  than  that  of 
opium."  It  is  otherwise  in  cases  of  melancholia,  especially  in  the 
more  chronic  forms.  In  these  opiates,  in  moderate  doses,  not  pushed 
to  excess,  may  be  given  with  great  advantage.  The  subcutaneous 
injection  of  morphia  is  by  far  the  best  means  of  exhibiting  the  drug, 
from  its  rapidity  of  action,  and  facility  of  administration. 

Other  Calmcdives. — There  are  other  methods  of  calming  the  excite- 
ment of  the  patient  besides  the  use  of  medicines.  The  prolonged 
use  of  the  warm  bath,  the  patient  being  immersed  in  water  at  a 
temperature  of  90^  or  92°  for  at  least  half  an  hour,  is  highly  recom- 
mended by  some  as  a  sedative.  The  wet  pack  serves  the  same  pur- 
pose, and  is  more  readily  applied  in  refractory  subjects. 

Importance  of  Judicious  Nursing. — Judicious  nursing  is  of  primary 
importance.  The  patient  should  be  kept  in  a  cool,  well  ventilated, 
and  somewhat  darkened  room.  If  possible  she  should  remain  in  bed, 
or,  at  least,  endeavors  should  be  made  to  restrain  the  excessive  rest- 
less motion,  which  has  so  much  effect  in  promoting  exhaustion.    The 


588  THE    PUERPERAL    STATE. 

presence  of  relatives  and  friends,  especially  the  husband,  has  gene- 
rally a  prejudicial  and  exciting  effect ;  and  it  is  advisable  to  place 
the  patient  under  the  care  of  nurses  experienced  in  the  management 
of  the  insane,  who,  as  strangers,  are  likely  to  have  more  control  over 
her.  It  is  not  too  much  to  say  that  much  of  the  success  in  treatment 
must  depend  on  the  manner  in  which  this  indication  is  met.  Eough, 
unskilled  nurses  who  do  not  know  how  to  use  gentleness  combined 
with  firmness,  will  certainlj'  aggravate  and  prolong  the  disorder. 
Inasmuch  as  no  patient  should  be  left  unwatched  by  day  or  night, 
more  than  one  nurse  is  essential. 

Question  of  Removal  to  an  Asylum. — The  question  of  the  removal 
of  the  patient  to  an  asylum  is  one  which  will  give  rise  to  anxious 
consideration.  As  the  fact  of  having  been  under  such  restraint  of 
necessity  fixes  a  certain  lasting  stigma  upon  a  patient,  this  is  a  step 
which  every  one  would  wish  to  avoid  if  possible.  In  cases  of  acute 
mania,  which  will  probably  last  a  comparatively  short  time,  home 
treatment  can  generally  be  efficiently  carried  out.  Much  must  depend 
on  the  circumstances  of  the  patient.  If  these  be  of  a  nature  which 
preclude  the  possibility  of  her  obtaining  thoroughly  efficient  nursing 
and  treatment  in  her  own  home,  it  is  advisable  to  remove  her  to  a 
place  where  these  essentials  can  be  obtained,  even  at  the  cost  of  some 
subsequent  annoyance.  In  cases  of  chronic  melancholia,  the  manage- 
ment of  which  is  on  the  whole  more  difficult,  the  necessity  for  such 
a  measure  is  more  likely  to  arise,  and  should  not  be  postponed  too 
late.  Many  examples  of  incurable  dementia,  arising  out  of  puerperal 
melancholia,  can  be  traced  to  unnecessary  delay  in  placing  the  patients 
under  the  most  favorable  conditions  for  recovery. 

Treatm.ent  during  Convalescence. — When  convalescence  is  com- 
mencing, change  of  air  and  scene  will  often  be  found  of  great  value. 
Kemoval  to  some  quiet  country  place,  where  the  patient  can  enjoy 
abundance  of  air  and  exercise,  in  the  company  of  her  nurses,  with- 
out the  excitement  of  seeing  many  people  is  especially  to  be  recom- 
mended. Great  caution  must  be  used  in  admitting  the  visits  of 
relatives  and  friends.  In  two  cases  under  my  own  care  the  patients 
relapsed,  when  apparently  progressing  favorably,  because  the  hus- 
bands insisted,  contrary  to  advice,  on  seeing  them.  On  the  other 
hand,  Gooch  has  pointed  out  that,  when  the  patient  is  not  recovering, 
when  month  after  month  has  been  passed  in  seclusion  without  any 
improvement,  the  visit  of  a  friend  or  relative  may  produce  a  favor- 
able moral  impression,  and  inaugurate  a  change  for  the  better.  It  is 
probably  in  cases  of  melancholia,  rather  than  in  mania,  that  this  is 
likely  to  happen.  The  experiment  may,  under  such  circumstances, 
be  worth  trying ;  but  it  is  one  the  result  of  which  we  must  contem- 
plate with  some  anxiety. 


PUERPERAL    SEPTICAEMIA.  689 


CHAPTEE   V. 

PUERPERAL  SEPTICEMIA. 

There  is  no  subject  in  the  whole  range  of  obstetrics  which  has 
caused  so  much  discussion  and  dift'erence  of  opinion  as  that  to  which 
this  chapter  is  devoted.  Under  the  name  of  "  Puerperal  Fever^'''  the 
disease  we  have  to  consider  has  given  rise  to  endless  controversy. 
One  writer  after  another  has  stated  his  view  of  the  nature  of  the 
affection  with  dogmatic  precision,  often  on  no  other  grounds  than  his 
own  preconceived  notions,  and  an  erroneous  interpretation  of  some 
of  the  post-mortem  appearances.  Thus,  one  states  that  puerperal 
fever  is  onl}^  a  local  inflammation,  such  as  peritonitis  ;  otliers  declare 
it  to  be  phlebitis,  metritis,  metro-peritonitis,  or  an  essential  zymotic 
disease  sui  generis^  which  affects  lying-in  women  only.  The  result 
has  been  a  hopeless  confusion ;  and  the  student  rises  from  the  stndy 
of  the  subject  with  little  more  useful  knowledge  than  when  he  began. 
Fortunately,  modern  research  is  beginning  to  throw  a  little  light  upon 
this  chaos. 

Modern  View  of  the  Disease. — The  Avhole  tendency  of  recent  inves- 
tigation is  daily  rendering  it  more  and  more  certain  that  obstetri- 
cians have  been  led  into  error  by  the  special  virulence  and  intensity 
of  the  disease,  and  that  they  have  erroneously  considered  it  to  be 
something  special  to  the  puerperal  state,  instead  of  recognizing  in  it 
a  form  of  septic  disease  practically  identical  with  that  which  is 
familiar  to  surgeons  under  the  name  of  pyjemia  or  septicaemia. 

Ohjection  to  the  Name. — If  this  view  be  correct,  the  term  "  puer- 
peral fever,"  conveying  the  idea  of  a  fever  such  as  typhus  or  typhoid, 
must  be  acknowledged  to  be  misleading,  and  one  that  should  be  dis- 
carded, as  only  tending  to  confusion.  Before  discussing  at  length 
the  reasons  which  render  it  probable  that  the  disease  is  in  no  way 
specific,  or  peculiar  to  the  puerperal  state,  it  will  be  w^ell  to  relate 
brieflv  some  of  the  leadinaj  facts  connected  with  it. 

History  of  the  Disease. — -More  or  less  distinct  references  to  the 
existence  of  the  so-called  puerperal  fever  are  met  with  in  the  classical 
authors,  proving,  beyond  doubt,  that  the  disease  was  well  known  to 
them ;  and  Hippocrates,  besides  relating  several  cases  the  nature  of 
which  is  unquestionable,  clearly  recognizes  the  possibility  of  its 
originating  in  the  retention  and  decomposition  of  portions  of  the 
placenta.  Although  Harvey  and  other  writers  showed  that  they 
were  more  or  less  familiar  with  it,  and  even  made  most  creditable 
observations  on  its  etiology,  it  was  not  until  the  latter  half  of  the  last 
century  that  it  came  prominently  info  notice.  At  that  time  the 
frightful  mortality  occurring  in  some  of  the  principal  lying-in  hos- 


590  THE    PUERPERAL    STATE. 

pitals,  especiallj  in  the  Hotel  Dieu  at  Paris,  attracted  attention  ;  and 
ever  since  the  disease  has  been  familiar  to  obstetricians. 

Mortality  resulting  from  it  in  Lyin<j-in  Hospitals. — Its  prevalence 
in  hospitals  in  vi^hich  lying-in  women  are  congregated  has  been  con- 
stantly observed  both  in  this  country  and  abroad,  occasionally  pro- 
ducing an  appalling  death-rate ;  the  disease,  when  once  it  has 
appeared,  frequently  spreading  from  one  patient  to  another,  in  spite 
of  all  that  could  be  done  to  arrest  it.  It  would  be  easy  to  give  many 
startling  instances  of  this.  Thus  it  prevailed  in  London  in  the  years 
1760,  1768,  and  1770,  to  such  an  extent  that  in  some  lying-in  insti- 
tutions nearly  all  the  patients  died.  Of  the  Edinburgh  Infirmary  in 
1773,  it  is  stated  that  "almost  every  woman,  as  soon  as  she  was  de- 
livered, or  perhaps  about  twenty-four  hours  after,  was  seized  with  it, 
and  all  of  them  died^  though  every  method  was  used  to  cure  the  dis- 
order."  On  the  Continent,  where  the  lying-in  institutions  are  on  a 
much  larger  scale,  the  mortality  was  equally  great.  Thus  in  the 
Maison  d'Accouchements  of  Paris,  in  a  number  of  different  years, 
sometimes  as  many  as  1  in  3  of  the  women  delivered  died ;  on  one 
occasion  10  women  dying  out  of  15  delivered.  Similar  results  were 
observed  in  other  great  Continental  hospitals,  as  in  Vienna,  vv'here, 
in  1823,  19  per  cent,  of  the  cases  died,  and,  in  1812,  16  per  cent. ;  and 
in  Berlin,  in  1862,  hardly  a  single  patient  escaped,  the  hospital  being 
eventually  closed. 

Such  facts,  the  correctness  of  which  is  beyond  any  question,  prove 
to  demonstration  the  great  risk  which  may  accompany  the  aggrega- 
tion of  lying-in  women.  Whether  they  justify  the  conclusion  that 
all  lying-in  hospitals  should  be  abolished,  is  another  and  a  very  wide 
question,  which  can  scarcely  be  satisfactorily  discussed  in  a  practical 
work.  It  is  to  be  observed,  however,  that  most  of  the  cases  in  which 
the  disease  produced  such  disastrous  results,  occured  before  our  more 
recent  knowledge  of  its  mode  of  propagation  was  acquired,  when  no 
sufficient  hygienic  precautions  were  adopted,  when  ventilation  was 
little  thought  of,  and  when,  in  a  word,  every  condition  prevailed 
that  would  tend  to  favor  the  spread  of  a  contagious  disease  from  one 
patient  to  another.  More  recent  experience  proves  that  when  the 
contrary  is  the  case  (as  for  example  in  such  an  institution  as  the 
Eotunda  Hospital  in  Dublin),  the  occurrence  of  epidemics  of  this 
kind  may  be  entirely  prevented,  and  the  mortality  approximated  to 
that  of  home  practice. 

The  Assumption  of  a  Puerperal  Miasm  is  Unnecessary. — The  more 
closely  the  history  of  these  outbreaks  in  hospitals  is  studied,  the 
more  apparent  does  it  become  that  they  are  not  dependent  on  any 
miasm  necessarily  produced  by  the  aggregation  of  puerperal  patients, 
but  on  the  direct  conveyance  of  septic  matter  from  one  patient  to 
another. 

In  numerous  instances  the  disease  has  been  said  to  be  generally 
epidemic  in  domiciliary  practice,  much  in  the  same  way  as  scarlet 
fever,  or  any  other  z^anotic  complaint,  might  be.  Such  epidemics 
are  described  as  having  occurred  in  London  in  1827—28,  in  Leeds  in 
1809-12,  in  Edinburgh  in  1825,  and  many  others  might  be  cited. 


PUERPERAL    SEPTICiEMIA.  591 

There  ]s,  however,  no  sufficient  ground  for  believing  that  the  disease 
has  ever  been  epidemic  in  the  strict  sense  of  the  word.  That  nume- 
rous cases  have  often  occurred  in  the  same  place,  and  at  the  same 
time,  is  beyond  question;  but  this  can  easily  be  explained  without 
admitting  an  epidemic  influence,  knowing,  as  we  do,  how  readily 
septic  matter  may  be  conveyed  from  one  patient  to  another.  In 
many  of  the  so-called  epidemics  the  disease  has  been  limited  to  the 
patients  of  certain  mid  wives  or  practitioners,  while  those  of  others 
have  entirely  escaped ;  a  fact  easily  understood  on  the  assumption 
of  the  disease  being  produced  by  septic  matter  conveyed  to  the 
patient,  but  irreconcilable  with  the  view  of  general  epidemic  influ- 
ence. We  are  not  in  possession  of  any  reliable  statistics  of  the  mor- 
tality arising  from  puerperal  septicaemia  in  ordinary  general  practice. 
It  has,  however,  been  well  pointed  out  in  the  Eoport  on  Puerperal 
Fever,  presented  by  the  Obstetrical  Society  of  Berlin  to  the  Prussian 
Minister  of  Health,^  that  not  only  do  the  published  returns  of  death 
from  metria  afford  no  reliable  estimate  of  the  actual  mortality  from 
this  source,  but  that  they  are  very  far  more  numerous  than  deaths 
from  any  other  cause  in  connection  witli  pregnancy  and  childbirth. 

Nuraeroiis  Theories  advanced  refjardimj  its  Nature. — It  would  be  a 
useless  task  to  detail  at  length,  the  theories  that  have  been  advanced 
to  explain  the  disease.  Indeed  it  may  safely  be  held  that  the  sup- 
posed necessity  of  providing  a  theory  which  would  explain  all  the 
facts  of  the  disease  has  done  more  to  surround  it  with  obscurity  than 
even  the  difficulties  of  the  subject  itself.  If  any  real  advance  is  to 
be  made,  it  can  only  be  by  adopting  an  liumDle  attitude,  by  admitting 
that  we  are  only  on  the  threshold  of  the  inquirj^,  and  by  a  careful 
observation  of  clinical  facts,  without  drawing  from  them  too  positive 
deductions. 

Theory  of  its  Local  Origin. — Many  have  taught  that  the  disease  is 
essentially  a  local  inilaramation,  producing  secondary  constitutional 
effects.  This  view  doubtless  originated  from  too  exclusive  attention 
to  the  morbid  changes  found  on  post-mortem  examination.  Exten- 
sive peritonitis,  phlebitis,  inflammation  of  the  lymphatics,  or  of  the 
tissues  of  the  uterus,  are  very  commonly  found  after  death  ;  and  each, 
of  these  has,  in  its  turn,  been  believed  to  be  the  real  source  of  the 
disease.  This  view  finds  but  little  favor  with  modern  pathologists, 
and  is  in  so  many  ways  inconsistent  with  clinical  facts,  that  it  may 
be  considered  to  be  obsolete.  No  one  of  the  conditions  above  men- 
tioned is  universally  found,  and  in  the  worst  cases,  definite  signs  of 
local  inflammation  may  be  entirely  absent.  Nor  will  this  theory 
explain  the  conveyance  of  the  disease  from  one  patient  to  another, 
or  the  peculiar  severity  of  the  constitutional  symptoms. 

Theory  of  an  Essential  Zymotic  Fever. — A  more  admissible  theory, 
and  one  which  has  been  extensively  entertained,  is,  that  there  is  an 
essential  zymotic  fever  peculiar  to,  and  only  attacking,  puerperal 
women,  which  is  as  specific  in  its  nature  as  typhus  or  typhoid,  and 
to  which  the  local  phenomena  observed  after  death  bear  the  same 

'  See  Edinburgh  Med.  Journ.,  Nov.  1878, 


592  THE    PUERPEEAL    STATE. 

relation  that  the  pustules  on  the  skin  do  to  smallpox,  or  the  ulcers 
in  the  intestinal  glands  to  typhoid.  This  fever  is  supposed  to  spread 
by  contagion  and  infection,  and  to  prevail  epidemically,  both  in 
private  and  in  hospital  practice.  The  most  recent  exponent  of  this 
view  is  Fordyce  Barker,  who,  in  his  excellent  work  on  the  "  Puer- 
peral Diseases,"  has  entered  at  length  into  all  the  theories  of  the 
disease.  He,  like  others  who  hold  his  opinions,  has,  I  cannot  but 
think,  entirely  failed  to  bring  forward  any  conclusive  evidence  of 
the  existence  of  such  a  specific  fever.  It  is  no  doubt  true  that  in 
typhus  and  typhoid,  and  other  undoubted  examples  of  this  class  of 
disease,  there  are  well-marked  local  secondary  phenomena ;  but  then 
they  are  distinct  and  constant.  He  makes  no  attempt  to  prove  that 
anything  of  the  kind  occurs  in  puerperal  fever.  On  the  contrarj^, 
probably  there  are  no  two  cases  in  which  similar  local  phenomena 
occur  ;  nor  is  there  any  case  in  which  the  most  practised  obstetrician 
could  foretell,  either  the  course  and  duration  of  the  illness,  or  the 
local  phenomena.  Again,  this  theory  altogether  fails  to  explain  the 
very  important  class  of  cases  which  can  be  distinctly  traced  to  sources 
originating  in  the  patient  herself,  viz.,  the  absorption  of  septic  matter 
from  decomposing  coagula,  and  the  like.  Barker  meets  this  difLiculty 
by  placing  such  cases  of  auto-infection  under  a  separate  category, 
admitting  that  they  are  examples  of  septiccemia.  But  he  fails  to 
show  that  there  is  any  difference  in  symptomatology  or  post-mortem 
signs  between  them  and  the  cases  he  believes  to  depend  on  an  essen- 
tial fever ;  nor  would  it  be  possible  to  distinguish  the  one  from  the 
other  by  either  their  clinical  or  pathological  history. 

Theory  of  Identity  with  Surgical  Se-pticEemia. — The  modern  view 
which  holds  that  the  disease  is,  in  fact,  identical  with  the  condition 
known  as  pyaemia  or  septicaemia,  is  by  no  means  free  from  objections, 
and  much  patient  clinical  investigation  is  required  to  give  a  satisfac- 
tory explanation  of  certain  peculiarities  which  the  disease  presents ; 
but,  in  spite  of  these  difficulties,  which  time  may  servo  to  remove,  it 
offers  a  far  better  explanation  of  the  phenomena  observed  than  any 
other  that  has  yet  been  advanced. 

Nature  of  this  View. — According  to  this  theory  the  so-called  puer- 
peral fever  is  produced  by  the  absorption  of  septic  matter  into  the 
system,  through  solutions  of  continuity  in  the  generative  tract,  such  as 
always  exist  after  labor.  It  is  not  essential  that  the  poison  should  be 
peculiar  or  specific ;  for,  just  as  in  surgical  pyoamia,  any  decomposing 
organic  matter,  either  originating  within  the  generative  organs  of  the 
patient  herself,  or  coming  from  without,  may  set  up  the  morbid  action. 

In  describing  the  disease  under  discussion,  I  shall  assume  that,  so 
far  as  our  present  knowledge  goes,  this  view  is  the  one  most  conso- 
nant with  facts ;  but,  bearing  in  mind  that  very  little  is  yet  known 
of  surgical  septic£emia,  it  must  not  be  expected  that  obstetricians 
can  satisfactorily  explain  all  the  phenomena  they  observe. 

Basis  of  Description. — The  best  basis  of  description  I  know  of,  is 
that  given  by  Burdon  Sanderson,  when  he  says,  "in  every  pyasmic 
process  you  may  trace  a  focus,  a  centre  of  origin,  lines  of  diffusion  or 
distribution,  and  secondary  results  from  the  distribution.     In  every 


PUERPERAL    SEPTICEMIA.  593 

case  an  initial  process  from  wbicli  infection  commences,  from  which 
the  infection  spreads,  and  secondary  processes  which  come  out  of 
this  primary  one."*  Adopting  this  division,  I  shall  first  treat  of 
the  mode  in  which  the  infection  may  commence  in  obstetric  cases, 
and  point  out  the  sj^ecial  difficulties  which  this  part  of  the  subject 
presents. 

Channels  through  which  Septic  Matter  may  he  Absorbed. — The  fact 
that  all  recently  delivered  women  present  lesions  of  continuity  in  the 
generative  tract,  through  whicli  septic  matter,  brought  into  contact 
with  them,  may  be  readily  absorbed,  has  long  been  recognized.  The 
analogy  between  the  interior  of  the  uterus  after  delivery  and  the 
surface  of  a  stump  after  operation,  was  particularly  insisted  on  by 
Cruveilhier,  Simpson,  and  others;  an  analogy  which  was,  to  a  great 
extent,  based  on  erroneous  conceptions  of  what  took  place,  since  they 
conceived  that  the  whole  interior  of  the  uterus  was  bared.  It  is  now 
well  known  that  that  is  not  the  case  ;  but  the  fact  remains  that  at  the 
placental  site,  at  any  rate,  there  are  open  vessels  through  which  ab- 
sorption may  readily  take  place.  That  absorption  of  septic  material 
occurs  through  this  channel  is  probable  in  certain  cases  in  which 
decomposing  materials  exist  in  the  interior  of  the  uterus,  especially 
when,  from  defective  uterine  contraction,  the  venous  sinuses  are  ab- 
normally patulous,  and  are  not  occluded  by  thrombi.  It  is  difficult 
to  understand  how  septic  matter,  introduced  from  without,  can  reach 
the  placental  site.  Other  sites  of  absorption  are,  however,  always 
available.  These  exist  in  every  case  in  the  form  of  slight  abrasions 
or  lacerations  about  the  cervix,  or  in  the  vagina,  or  especially  in 
primiparse,  about  the  fourchette  and  perineum.  There  is  even  some 
reason  to  think  that  absorption  of  septic  matter  may  take  place 
through  the  mucous  membrane  of  the  vagina  or  cervix  without  any 
breach  of  surface.  This  might  serve  to  account  for  the  occasional, 
although  rare  cases,  in  which  symptoms  of  the  disease  develop  them- 
selves before  delivery,  or  so  soon  after  it  as  to  show  that  the  infection 
must  have  preceded  labor ;  nor  is  there  any  inherent  improbability 
in  the  supposition  that  septic  material  mav  be  occasionally  absorbed 
through  the  unbroken  mucous  membrane,  as  is  certainly  the  case 
with  some  poisons,  for  example  that  of  syphilis.  Hence  there  is  no 
difficulty  in  recognizing  the  similarity  of  a  lying-in  woman  to  a  pa- 
tient suffering  from  a  recent  surgical  lesion,  or  in  understanding  how 
septic  matter  conveyed  to  her,  during  or  shortly  after  labor,  may  be 
absorbed.  It  is  necessary,  however,  to  suppose  that  absorption  takes 
place  immediately  or  very  shorth^  after  these  lesions  of  continuity 
are  formed,  for  it  is  well  known  that  the  power  of  absorption  is 
arrested  after  they  have  commenced  to  heal.  This  fact  may  explain 
the  cases  in  which  sloughing  about  the  perineum  or  vagina  exists 
without  any  septiceemia  resulting,  or  the  far  from  uncommon  cases, 
in  which  an  intensely  fetid  lochial  discharge  may  be  present  a  few 
days  after  delivery,  without  any  infection  taking  place. 

The  character  and  sources  of  the  septic  matter  constitute  one  of 

'  Clinical  Transactions,  vol.  viii.  p.  cviii. 


594  THE    PUERPERAL    STATE. 

the  most  obscure  questions  in  connection  with  septicaemia,  and  that 
which  is  most  open  to  discussion. 

The  most  practical  division  of  the  subject  is  into  cases  in  which 
the  septic  matter  originates  within  the  patient,  so  that  she  infects 
herself,  the  disease  then  being  properly  autoyenetic ;  and  into  those 
in  which  the  septic  matter  is  conveyed  from  without,  and  brought 
into  contact  with  absorptive  surfaces  in  the  generative  tract,  the  dis- 
ease then  being  heterogenetic. 

Sources  of  Self-infection. — The  sources  of  auto-infection  may  be 
various,  but  they  are  not  difficult  to  understand.  Any  condition 
giving  rise  to  decomposition,  either  of  the  tissues  of  the  mother 
herself,  of  matters  retained  in  the  uterus  or  vagina  that  ought  to 
have  been  expelled,  or  decomposing  matter  derived  from  a  putrid 
foetus,  may  start  the  septic£emic  process.  Thus  it  may  happen  that 
from  continuous  pressure  on  the  maternal  soft  parts  during  labor, 
sloughing  has  set  in ;  or  there  may  be  already  decomposing  material 
present  from  some  previous  morbid  state  of  the  genital  tracts,  as  in 
carcinoma.  A  more  common  origin  is  the  retention  of  coagula,  or 
of  small  portions  of  membrane,  or  of  placenta,  in  the  interior  of  the 
uterus,  which  have  putrefied  from  access  of  air ;  or  in  the  decompo- 
sition of  the  lochia.  That  the  retention  of  portions  of  the  placental 
tissue  has  at  all  times  been  the  cause  of  septicemia  may  be  illustrated 
by  the  case  of  the  Duchesse  d'Orleans,  in  the  time  of  Louis  XIII., 
who  had  an  easy  labor,  but  died  of  child-bed  fever.  An  examination 
was  made  by  the  leading  physicians  of  Paris,  in  their  report  of  which 
it  was  stated,  "  On  the  right  side  of  the  womb  was  found  a  small 
portion  of  after-birth,  so  firmly  adherent  that  it  could  hardly  be  torn 
off  by  the  finger  nails. "^  The  reason  Avhy  self-infection  does  not 
more  often  occur  from  such  sources,  since  more  or  less  decomposition 
is  of  necessity  so  often  present,  has  already  been  referred  to  in  the 
fact  that  absorption  of  such  matters  is  not  apt  to  occur  when  the 
lesions  of  continuity,  always  existing  after  parturition,  have  com- 
menced to  heal.  This  observation  may  also  serve  to  explain  how 
previous  bad  states  of  health,  by  interfering  with  the  healthy  repa- 
rative process  occurring  after  delivery,  may  predispose  to  self-infec- 
tion. It  is  interesting  to  note  that  puerperal  septicaemia,  arising 
from  such  sources,  is  not  limited  to  the  human  race.  In  the  debate 
on  pya?ania  at  the  Clinical  Society  .Mr.  Hutchinson  recorded  several 
well-marked  examples  occurring  in  ewes,  in  whose  uteri  portions  of 
retained  placenta  were  found. 

Source  of  Heterogenetic  Infection. — The  sources  of  septic  matter 
conveyed  from  without  are  much  more  difficult  to  trace,  and  there 
are  many  facts  connected  with  heterogenetic  infection  which  are  very 
difficult  to  reconcile  with  theory,  and  of  which,  it  must  be  admitted, 
we  are  not  yet  able  to  give  a  satisfactory  explanation. 

It  is  probable  that  any  decomposing  organic  matter  may  infect, 
but  that  some  forms  operate  with  more  certainty  and  greater  viru- 
lence than  others. 

'  Louise  Bourgeois,  by  Goodell. 


PUERPERAL    SEPTICiEMIA.  595 

Influence  of  Cadaveric  Poisoning. — One  of  these,  which  has  attracted 
special  attention,  is  what  may  be  termed  cadaveric  poison,  derived 
from  dissection  of  the  dead  suVjject  in  the  anatomical  and  post-mortem 
theatre,  and  conveyed  to  the  genital  tract  by  the  hands  of  the  accou- 
cheur. Attention  was  particularly  directed  to  this  source  of  infec- 
tion by  the  observations  of  Semmelweiss,  who  showed  that  in  the 
division  of  the  Vienna  Ljnng-in  Hospital  attended  by  medical  men 
and  students  who  frequented  the  dissecting  rooms,  the  mortality  was 
seldom  less  than  1  in  10,  while  in  the  division  solely  attended  by 
women,  the  mortality  never  exceeded  1  in  34 ;  the  number  of  deaths 
in  the  former  division  at  once  falling  to  that  of  the  latter,  as  soon  as 
proper  precautions  and  means  of  disinfection  were  used.  Many  other 
facts  of  a  like  nature  have  since  been  recorded,  which  render  this 
origin  of  puerperal  septicaemia  a  matter  of  certainty.  An  interesting 
example  is  related  by  Simpson  with  characteristic  candor: — "In 
1836  or  1837  Mr.  Sidey  of  this  city  had  a  rapid  succession  of  five  or 
six  cases  of  puerperal  fever  in  his  practice,  at  a  time  when  the  dis- 
ease was  not  known  to  exist  in  the  practice  of  any  other  j^ractitioners 
in  the  locality.  Dr.  Simpson,  who  had  then  no  firm  or  proper  belief 
in  the  contagious  propagation  of  puerperal  fever,  attended  the  dis- 
section of  Mr.  Sidey's  patients,  and  freely  handled  the  diseased  parts. 
The  next  four  cases  of  midwifery  which  Dr.  Simpson  attended  were 
all  affected  with  puerperal  fever,  and  it  was  the  first  time  he  had 
seen  it  in  practice.  Dr.  Patterson,  of  Leith,  examined  the  ovaries, 
etc.  The  three  next  cases  which  Dr.  Patterson  attended  in  that  town 
were  attacked  with  the  disease."^  Negative  examples  are  of  course 
brought  forward  of  those  who  have  attended  post-mortem  examina- 
tions without  injury  to  their  obstetric  patients,  which  merely  prove 
that  the  cadaveric  poison  does  not,  of  necessity,  attach  itself  to  the 
hands  of  the  dissector ;  and  no  amount  of  such  testimony  can  invali- 
date such  positive  evidence  as  that  just  narrated.  Barnes  believes 
that  there  is  not  so  much  danger  attending  the  dissection  of  patients 
who  have  died  of  any  ordinary  disease,  but  that  the  risk  attending 
the  dissection  of  those  who  have  died  of  infectious  or  contagious 
complaints  is  very  great  indeed.^  I  presume  there  is  no  doubt  that 
the  risk  is  greater  when  the  subject  has  died  from  zymotic  disease ; 
but  the  distinction  is  too  delicate  to  rely  on,  and  the  attendant  on 
midwifery  will  certainly  err  on  the  safe  side  by  avoiding,  as  much  as 
possible,  having  anything  to  do  with  the  conduct  of  dissections  or 
post-mortem  examinations. 

Infection  from  Erysipelas. — ^ Another  possible  source  of  infection  is 
erysipelatous  disease  in  all  its  forms.  The  intimate  connection  be- 
tween erysipelas  and  surgical  py^eniia  has  long  been  recognized  by 
surgeons,  and  the  influence  of  erysipelas  in  producing  puerperal 
septicaemia  has  been  especially  observed  in  surgical  hospitals  in 
which  lyiTig-in  patients  were  also  admitted.  Trousseau  relates  in- 
stances of  this  kind  occurring  in  Paris.     The  only  instance  that  I 

'  Selected  Obst.  Works,  p.  508. 

2  "  Lectures  on  Puerperal  Fever,"  Lancet,  vol.  ii.  1865. 


596  THE    PUERPERAL    STATE. 

know  of  in  London  was  in  tlie  lying-in  ward  of  King's  College 
Hospital,  where,  in  spite  of  every  hygienic  precaution,  the  mortality 
was  so  great  as  to  necessitate  the  clbsare  of  the  ward.  Here  the 
association  of  erysipelas  with  puerperal  septicaemia  was  again  and 
again  observed ;  the  latter  proving  fatal  in  direct  proportion  to  the 
prevalence  of  the  former  in  the  surgical  wards.  The  dependence  of 
the  two  on  the  same  poison  was  in  one  instance  curiouslv  shown  by 
the  fact  of  the  child  of  a  patient  who  died  of  puerperal  septicaemia, 
dying  from  erysipelas  which  started  from  a  slight  abrasion  produced 
by  the  forceps.  A  more  recent  and  very  remarkable  example  is 
related  by  Dr.  Lombe  Atthill.^  A  patient  suffering  from  erysipelas 
was  admitted  into  the  Eotunda  Hospital  on  February  15, 1877.  The 
sanitary  condition  of  the  hospital  was  at  the  time  excellent-  The 
patient  was  removed  next  day ;  but  of  the  next  10  patients  confined 
in  adjoining  wards,  9  were  attacked  with  puerperal  peritonitis,  the 
only  one  who  escaped  being  a  case  of  abortion.  But  the  connection 
between  erysipelas  and  puerperal  septicaemia  is  not  limited  to  hospi- 
tals, having  been  often  observed  in  domiciliary  practice.  Some 
interesting  facts  have  been  collected  by  Dr.  Minor,^  who  has  shown 
that  the  two  diseases  have  frequently  prevailed  together  in  various 
parts  of  the  United  States,  and  that  during  a  recent  outbreak  of 
puerperal  fever  in  Cincinnati,  it  occurred  chiefly  in  the  practice  of 
those  physicians  who  attended  cases  of  erysipelas.  Many  children 
also  died  from  erysipelas,  whose  mothers  had  died  from  puerperal 
fever. 

Infection  from  other  Zymotic  Diseases. — There  is  good  reason  to 
believe  that  the  contagium  of  other  zymotic  diseases  may  produce  a 
form  of  disease  indistinguishable  from  ordinary  puerperal  septicsemia, 
and  presenting  none  of  the  characteristic  features  of  the  specific 
complaint  from  which  the  contagium  was  derived.  This  is  admitted 
to  be  a  fact  by  the  majority  of  our  most  eminent  Britisli  obstetri- 
cians, although  it  does  not  seem  to  be  allowed  by  Continental  authori- 
ties, and  it  is  strongly  controverted  by  some  writers  in  this  country. 
It  is  certainly  difficult  to  reconcile  this  with  the  theory  of  septicae- 
mia, and  we  are  not  in  a  position  to  give  a  satisfactory  explanation 
of  it.  I  believe,  however,  that  the  evidence  in  favor  of  the  possi- 
bility of  puerperal  septicaemia  originating  in  this  way  is  too  strong 
to  be  assailable. 

The  scarlatinal  poison  is  that  regarding  which  the  greatest  number 
of  observations  have  been  made.  Numerous  cases  of  this  kind  are 
to  be  found  scattered  through  our  obstetric  literature,  but  the  largest 
number  are  to  be  met  with  in  a  paper  by  Dr.  Braxton  Hicks  in  the 
12th  volume  of  the  "Obstetrical  Transactions,"  and  they  are  especi- 
ally valuable  from  that  gentleman's  well-known  accuracy  as  a  clinical 
observer.  Out  of  QS  cases  of  puerperal  disease  seen  in  consultation, 
no  less  than  37  were  distinctly  traced  to  the  scarlatinal  poison.  Of 
these  20  had  the  characteristic  rash  of  the  disease ;  but  the  remain- 

'  Medical  Press  and  Circular,  April,  1877. 

2  Erysipelas  and  Childbed  Fever.     Cincinnati,  1874. 


PUERPERAL    SEPTICAEMIA.  597 

ing  17,  although  the  history  clearly  proved  exposure  to  tlie  conta- 
gium  of  scarlet  fever,  showed  none  of  its  usual  symptoms,  and  were 
not  to  be  distinguished  from  ordinary  typical  cases  of  the  so-called 
puerperal  fever.  On  the  theory  that  it  is  impossible  for  the  specific 
contagious  diseases  to  be  modified  by  the  puerperal  state,  we  have  to 
admit  that  one  physician  met  with  17  cases  of  ])uerperal  septicaemia 
in  which,  by  a  mere  coincidence,  the  contagion  of  scarlet  fever  had 
been  traced,  and  that  the  disease  nevertheless  originated  from  some 
other  source;  an  hypothesis  so  improbable,  that  its  mere  mention 
carries  its  own  refutation. 

With  regard  to  the  other  zymotic  diseases  the  evidence  is  not  so 
strong;  probably  from  the  comparative  rarity  of  the  disej'ses.  liicks 
mentions  one  case  in  which  the  diphtheritic  poison  was  traced,  al- 
though none  of  the  usual  phenomena  of  the  disease  were  present.  I 
lately  saw  a  case  in  which  a  lady,  a  few  days  after  delivery,  had  a 
very  serious  attack  of  septicaemia,  without  any  diphtheritic  symp- 
toms, her  husband  being  at  the  same  time  attacked  with  diphtheria 
of  a  most  marked  type.  Plere  it  would  be  difficult  not  to  admit  the 
dependence  of  the  two  diseases  on  the  same  poison. 

It  is,  however,  certain  that  all  the  zymotic  diseases  may  attack  a 
newly  delivered  woman,  and  run  their  characteristic  course  without 
any  peculiar  intensity.  Probably  most  practitioners  have  seen  cases 
of  this  kind ;  and  this  is  precisely  one  of  the  points  of  difficulty 
which  we  cannot  at  present  explain,  but  on  which  future  research 
may  be  expected  to  throw  some  light.  It  seems  to  me  not  improba- 
ble, that  the  explanation  of  the  fact  that  zymotic  poison  may  in  one 
puerperal  patient  run  its  ordinary  course,  and  in  another  produce 
symptoms  of  intense  septicaemia,  may  be  found  in  the  channel  of 
absorption.  It  is  at  any  rate  comprehensible  that  if  the  contagium 
be  absorbed  through  the  skin  or  the  ordinary  channels,  it  may  pro- 
duce its  characteristic  symptoms,  and  run  its  usual  course ;  while  if 
brought  into  contact  with  lesions  of  continuity  in  the  generative 
tract,  it  may  act  more  in  the  way  of  septic  poison,  or  with  such  in- 
tensity that  its  specific  symptoms  are  not  developed. 

It  may  reasonably  be  objected  that  if  puerperal  and  surgical  sep- 
ticaemia be  identical,  the  zymotic  poisons  ought  to  be  similarly  modi- 
fied when  they  infect  patients  after  surgical  operations.  The  subject 
of  specific  contagium  as  a  cause  of  surgical  pyaemia  has  been  so  little 
studied,  that  I  do  not  think  any  one  would  be  justified  in  asserting 
that  such  an  occurrence  is  not  possible.  Fritsch,  of  Halle,  and  other 
German  physicians,  have  recently  shown  hoAV  elaborate  antiseptic 
precautions  in  lying-in  hospitals  may  prevent  the  origin  of  the  dis- 
ease from  such  sources.  Sir  James  Paget,  in  his  "Clinical  Lectures," 
seems  to  believe  in  the  possibility  of  such  modification.  He  says, 
"  I  think  it  not  improbable  that,  in  some  cases,  results  occurring  with 
obscure  symptoms,  within  two  or  three  days  after  operations,  have 
been  due  to  the  scarlet-fever  poison,  hindered  in  some  way  from  its 
usual  progress."  Mr.  Spencer  Wells  informs  me  that  he  has  seen 
cases  of  surgical  pyaemia,  which  he  had  reason  to  believe  originated 
in  the  scarlatinal  poison ;  and  his  well-known  success  as  an  ovario- 


598  THE    PUERPERAL    STATE. 

tomist  is,  no  doubt,  in  a  great  measure  to  be  attributed  to  his  extreme 
care  in  seeing  that  no  one,  likely  to  come  in  contact  with  his  patients, 
has  been  exposed  to  any  such  source  of  infection. 

^ejAicsemia  f rom  Conia(jion  conveyed  from  other  Puerperal  Patients. — - 
The  last  source  from  which  septic  matter  may  be  conveyed  is  from  a 
patient  suffering  from  puerperal  septicosmia,  a  mode  of  origin  Avhich 
has,  of  late,  attracted  special  attention.  That  this  is  the  explanation 
of  the  occasional  endemic  prevalence  of  the  disease  in  lying-in  hos- 
pitals can  scarcely  be  doubted.  The  theory  of  a  special  puerperal 
miasm  pervading  the  hospital  is  not  required  to  account  for  the  facts, 
for  there  are  a  hundred  ways,  impossible  to  detect  or  avoid — -on  the 
hands  of  nurses  or  attendants,  in  sponges,  bed-pans,  sheets,  or  even 
suspended  in  the  atmosphere — in  which  septic  material,  derived  from 
one  patient,  may  be  carried  to  another. 

The  poison  may  be  conveyed,  in  the  same  manner,  from  one  pri- 
vate patient  to  another.  Of  this  there  are  many  lamentable  instances 
recorded.  Thus  it  w^as  mentioned  by  a  gentleman  at  the  recent  dis- 
cussion at  the  Obstetrical  Society,  that  5  out  of  14  women  he  attended 
died,  no  other  practitioner  in  the  neighborhood  having  a  case.  This 
origin  of  the  disease  was  clearly  pointed  out  by  Gordon^  towards  the 
end  of  last  century,  who  stated  that  he  himself  "was  the  means  of 
carrying  the  infection  to  a  great  number  of  Avomen,"  and  he  also 
traced  the  spread  of  the  disease  in  the  same  way  in  the  practice  of 
certain  midwives.  In  some  remarkable  instances  the  unhappy  prop- 
erty of  carrying  contagion  has  clung  to  individuals  in  a  way  which 
is  most  mysterious,  and  which  has  led  to  the  supposition  that  the 
whole  system  becomes  saturated  with  the  poison.  One  of  the 
strangest  cases  of  this  kind  was  that  of  Dr.  Eutter,  of  Philadelphia, 
which  caused  much  discussion.  He  had  45  cases  of  puerperal  septi- 
cti3mia  in  his  own  practice  in  one  year,  while  none  of  his  neighbors' 
patients  were  attacked.  Of  him  it  is  related,  "Dr.  Rutter,  to  rid 
himself  of  the  mysterious  influence  which  seemed  to  attend  "upon 
his  practice,  left  the  city  for  ten  days,  and  before  waiting  on  the 
next  parturient  case  had  his  hair  shaved  off,  and  put  on  a  wig,  took 
a  hot  bath,  and  changed  every  article  of  his  apparel,  taking  nothing 
with  him  that  he  had  worn  or  carried  to  his  knowledge  on  any 
former  occasion :  and  mark  the  result.  The  lady,  notwithstanding 
that  she  had  an  easy  parturition,  was  seized  the  next  day  with  child- 
bed fever,  and  died  on  the  eleventh  day  after  the  birth  of  the  child. 
Two  years  later  he  made  another  attempt  at  self-purification,  and  the 
next  case  attended  fell  a  victim  to  the  same  disease."  No  wonder 
that  Meigs,  in  commenting  on  such  a  history,  refused  to  believe  that 
the  doctor  carried  the  poison,  and  rather  thought  that  he  was  "merely 
unhappy  in  meeting  with  such  accidents  through  God's  providence." 
It  appears,  however,  that  Dr.  Rutter  was  the  subject  of  a  form  of 
ozosna,  and  it  is  quite  obvious  that,  under  such  circumstances,  his 
hands  could  never  have  been  free  from  septic  matter.^    [The  Author 

'  See  Lectures  on  Puerperal  Fever.     By  Robert  J.  Lee,  M.D. 

2  This  is  stated  on  the  authority  of  an  obstetrical  contemporary  of  Dr.  Rutter.  See 
Ainer.  Journ.  of  Med.  Sciences,  April,  1875,  p.  471. 


PUERPERAL    SEPTICAEMIA.  599 

quotes  from  the  Editor,  Dr.  Rutter  had  an  ozoena  which  in  time  much 
disfigured  him  from  its  effect  upon  the  contour  of  his  nose.  Ue  was 
unfortunately  inoculated  in  his  index  finger  from  a  patient,  and 
neglected  the  pustule.  He  had  95  cases  of  puerperal  se[)tica;mia  in 
4  years  and  9  months,  with  18  deaths.  The  question  of  Dr.  Meigs, 
who  was  a  non-ct)ntagionist  in  regard  to  puerperal  peritonitis,  Avas 
remarkably  apposite,  "did  he  distil  a  subtle  essence  which  he  carried 
with  him  ?" — Ed.]  This  observation  is  of  peculiar  interest  as  show- 
ing that  the  sources  of  infection  may  exist  in  conditions  difficult 
to  suspect  and  impossible  to  obviate,  and  it  affords  a  satisfactory 
explanation  of  a  case  which  was  for  years  considered  puzzling  in 
the  extreme.  It  is  quite  possible  that  other  similar  cases,  of  which 
many  are  on  record,  although  none  so  remarkable,  may  possibly 
have  depended  on  some  similar  cause  personal  to  the  medical  at- 
tendant. 

The  sources  of  septic  poison  being  thus  multifarons,  a  few  words 
may  be  said  as  to  the  mode  in  which  it  may  be  conveyed  to  the 
patient. 

Mode  in  wliich  the  Poison  may  he  Conveyed  to  the  Patient. — As  on 
the  view  of  puerperal  septicaemia  which  seems  most  to  agree  with 
recorded  facts,  the  poison,  from  whatever  source  it  may  be  derived, 
must  come  into  actual  contact  with  lesions  of  continuity  in  the  gene- 
rative tract,  it  is  obvious  that  one  method  of  conveyance  may  be  on 
the  hands  of  the  accoucheur.  That  this  is  a  possibility,  and  that  the 
disease  has  often  been  unhappily  conveyed  in  this  way,  no  one  can 
doubt.  Still  it  would  be  unfair  in  the  extreme  to  conclude  that  this 
is  the  only  way  in  which  infection  may  arise.  In  town  practice, 
especially,  there  are  many  other  ways  in  which  septic  matter  may 
reach  the  patient.  The  nurse  may  be  the  means  of  communication, 
and,  if  she  have  been  in  contact  with  septic  matter,  she  is  even  more 
likely  than  the  medical  attendant  to  conve}^  it  when  Avashing  the 
genitals  during  the  first  few  days  after  delivery,  the  time  that  ab- 
sorption is  most  apt  to  occur.  Barnes  relates  a  whole  series  of  cases 
occurring  in  a  suburb  of  London,  in  the  practice  of  different  practi- 
tioners, every  one  of  which  was  attended  by  the  same  nurse.  Again 
septic  matter  may  be  carried  in  sponges,  linen,  and  other  articles. 
What  is  more  likely,  for  example,  than  that  a  careless  nnrse  might  use 
an  imperfectly  washed  sponge,  on  which  discharge  has  been  allowed 
to  remain  and  decompose?  Nor  do  I  see  any  reason  to  question  the 
possibility  of  infection  from  septic  matter  suspended  in  the  atmo- 
sphere ;  and  in  lying-in  hospitals,  where  many  women  are  congre- 
gated together,  there  can  be  little  doubt  that  this  is  a  common  origin 
of  the  disease.  It  is  certain,  whatever  view  we  may  take  of  the 
character  of  the  septic  material,  that  it  must  be  in  a  state  of  very 
minute  subdivision,  and  there  is  no  theoretical  difficulty  in  the 
assumption  of  its  being  conveyed  by  the  atmosphere. 

Conduct  of  the  Practitioner  in  relation  to  the  Disease. — This  ques- 
tion naturally  involves  a  reference  to  the  duty  of  those  who  are 
unfortunately  brought  into  contact  with  septic  matter  in  any  form, 
either  in  a  patient  suffering  from  puerperal  septicaemia,  zymotic  dis- 


600  THE    PUERPERAL    STATE. 

ease,  or  offensive  discharges.  The  practitioner  cannot  always  avoid 
such  contact,  and  it  is  practically  impossible,  as  Dr.  Duncan  has  in- 
sisted, to  relinquish  obstetric  work  every  time  that  he  is  in  attendance 
on  a  case  from  which  contagion  may  be  carried.  Nor  do  I  believe, 
especially  in  these  days  when  the  use  of  antiseptics  is  so  well  under- 
stood, that  it  is  essential.  It  was  otherwise  when  antiseptics  were 
not  employed ;  but  I  can  scarcely  conceive  any  case  in  which  the 
risk  of  infection  cannot  be  prevented  by  proper  care.  The  danger  I 
believe  to  be  chiefly  in  not  recognizing  the  possible  risk,  and  in  ne- 
glecting the  use  of  proper  precautions.  It  is  impossible,  therefore, 
to  urge  too  strongly  the  necessity  of  extreme  and  even  exaggerated 
care  in  this  direction.  The  practitioner  should  accustom  himself,  as 
much  as  possible,  to  use  the  left  hand  only  in  touching  patients  suf- 
fering from  infectious  diseases,  as  that  which  is  not  used,  under  ordi- 
nary circumstances,  in  obstetric  manipulations.  He  should  be  most 
careful  in  the  frequent  employment  of  antiseptics  in  washing  his 
hands,  such  as  Condy's  fluid,  carbolic  acid,  or  tincture  of  iodine. 
Clothing  should  be  changed  on  leaving  an  infectious  case.  Much 
more  care  than  is  usually  practised  should  be  taken  by  nurses,  espe- 
cially in  securing  perfect  cleanliness  in  everything  brought  into 
contact  with  the  patient.  When,  however,  a  practitioner  is  in  actual 
and  constant  attendance  on  a  case  of  puerperal  septicasmia,  when  he 
is  visiting  his  patient  many  times  a  day,  especiall}^  if  he  be  himself 
washing  out  the  uterus  with  antiseptic  lotions,  it  is  certain  that  he 
cannot  deliver  other  patients  with  safety,  and  he  should  secure  the 
assistance  of  a  brother  practitioner^  although  there  seems  no  reason, 
why  he  should  not  visit  women  already  confined,  in  whom  he  has  not 
to  make  vaginal  examinations. 

Prophylaxis  of  Septicaemia. -^-1^  the  views  here  inculcated  as  to  the 
nature  of,  and  mode  of  infection  in,  puerperal  septicseraia  be  correct, 
it  is  obvious  that  much  may  be  done  in  the  way  of  prophylaxis. 
A  perfectly  aseptic  management  of  puerperal  women  is  practically 
impossible.  In  many  lying-in  institutions  on  the  Continent,  and  in 
some  in  this  country,  very  rigid  rules  have  been  laid  down  to  pre- 
vent the  possibility  of  infective  matter  being  conveyed  to  the  patient 
either  on  the  hands  of  the  attendants  or  on  instruments,  napkins,  and 
the  like,  and  it  is  said,  with  very  satisfactory  results.  As  the  risk  is 
much  greater  when  lying-in  women  are  collected  together,  such  pre- 
cautions, which  this  is  not  the  place  to  discuss,  are  absolutely  indi- 
cated. They  are  not,  however,  applicable  in  ordinary  private  prac- 
tice ;  but  there  are  certain  simple  precautions  which  every  one  might 
adopt  without  trouble,  which  will  materially  lessen  the  risk  of  septic 
poisoning.  Amongst  these  may  be  indicated  the  use  of  a  lotion  of 
1  in  20  carbolic  acid,  with  which  the  practitioner  and  nurse  should 
always  wash  their  hands  before  attending  any  case,  or  touching  the 
genital  organs ;  the  use  of  carbolized  oil,  1  in  8,  for  lubricating  the 
fingers,  catheter,  forceps,  etc. ;  syringing  out  the  vagina  night  and 
morning  with  diluted  Condy's  fluid ;  rigid  attention  to  cleanliness 
in  bedding,  napkins,  etc.  Precautions  such  as  these,  although  they 
may  appear  to  some  frivolous  and  useless,  indicate  a  recognition  of 


PUERPERAL    SEPTICiEMrA.  601 

danger  and  an  endeavor  to  remove  it,  and  if  tbej  were  generally 
inculcated  on  nui'ses  and  others,  niiglit  go  far  to  prevent  the  occur- 
rence of  septic  mischief. 

Nature  of  the  Septic  Poison. — As  to  the  precise  character  of  the 
septic  poison — although  of  late  much  has  been  said  about  it,  and 
there  is  good  reason  to  believe  that  further  research  may  throw  light 
on  this  obscure  subject — too  little  is  known  to  justify  any  positive 
statement.  With  regard  to  the  influence  of  the  minute  organisms 
known  as  bacteria,  and  their  supposed  connection  with  the  produc- 
tion of  the  disease,  this  is  especially  the  case.  Heiberg  has  proved 
that  they  may  bo  traced,  in  most  cases  of  puerperal  septicaemia,  pass- 
ing through  the  veins  and  lymphatics,  and  that  they  are  found  in 
various  organs  and  pathological  products.  But  what  their  relation 
is  to  the  disease,  whether  they  themselves  form  the  septic  matter,  or 
carry  it,  or  whether  they  are  mere  accidental  concomitants  of  the 
pytetnic  processes,  it  is  impossible,  in  the  present  state  of  our  knowl- 
edge, to  state ;  and  I,  therefore,  prefer  to  dwell  on  that  part  of  the 
subject  which  is  of  clinical  importance,  rather  than  enter  into  specu- 
lative theories,  which  may  to-morrow  prove  to  be  valueless. 

Channels  of  Diffusion. — Passing  on  to  the  channels  of  diffusion 
through  which  the  septic  matter  may  act,  we  have  to  consider  its 
effects  on  the  structures  with  which  it  is  brought  into  contact,  and 
the  mode  in  which  it  may  infect  the  system  at  large;  and  this  will 
include  a  consideration  of  the  pathological  phenomena. 

Local  changes  consequent  on  the  absorption  of  the  poison  are  pretty 
constant,  and  of  these  we  may  form  an  intelligible  idea  by  thinking 
of  them  as  similar  in  character  and  causation  to  those  which  we  have 
the  opportunity  of  studying  when  septic  matter  is  applied  to  a  wound 
open  to  observation,  as,  for  example,  in  cases  of  blood-poisoning  fol- 
lowing a  dissection  wound.  Distinct  traces  of  local  action  are  not  of 
invariable  occurrence,  and  in  some  of  the  worst  class  of  cases,  when 
the  amount  of  septic  matter  is  great,  and  its  absorption  rapid,  death 
may  occur  after  an  illness  of  short  duration  but  great  intensity,  and 
before  appreciable  local  changes,  either  at  the  site  of  absorption  or 
in  the  system  at  large,  have  had  time  to  develop  themselves.  The 
fact  that  puerperal  fever  may  prove  fatal,  without  leaving  any  tan- 
gible post-mortem  signs,  has  often  been  pointed  out,  such  cases  most 
frequently  occurring  during  the  endemic  prevalence  of  the  disease  in 
lying-in  hospitals.  There  can  be  little  doubt,  however,  that  in  such 
cases  of  intense  septic£emia  marked  pathological  changes  exist,  in  the 
form  of  alterations  of  the  blood  and  degenerations  of  tissue,  but  not 
of  a  character  which  can  be  detected  by  an  ordinary  post-mortem 
examination.  In  the  great  majority  of  cases,  indications  of  the  dis- 
ease exist  at  the  site  of  absorption.  These  are  described  by  patholo- 
gists as  identical  in  their  character  with  the  inflammatory  oedema 
which  occurs  in  connection  with  phlegmonous  erysipelas.  If  lacera- 
tions exist  in  the  cervix  or  vagina  they  take  on  unhealthy  action, 
their  edges  swell,  and  their  surfaces  become  covered  with  a  yellowish 
coat,  similar  in  appearance  to  diphtheritic  membrane.  The  mucous 
membrane  of  the  uterus  is  also  generally  found  to  be  affected,  and 
39 


602  THE    PUERPERAL    STATE. 

in  a  degree  varying  with  the  intensity  of  the  local  septic  process. 
There  is  evidence  of  severe  endometritis ;  and,  very  frequently,  the 
whole  lining  of  the  uterus  is  profoundly  altered,  softened,  covered 
with  patches  of  diphtheritic  deposit,  and  it  may  be  in  a  state  of 
general  necrosis.  In  the  severer  cases  these  changes  affect  the  mus- 
cular tissue  of  the  uterus,  which  is  found  to  be  swollen,  soft,  imper- 
fectly contracted,  and  even  partially  necrosed,  a  condition  which  is 
likened  by  Heiberg  to  hospital  gangrene.  The  connective  tissue 
surrounding  the  generative  tract  is  also  swollen  and  oedematous,  and 
the  inflammation  may  in  this  way  reach  the  peritoneum,  although 
peritonitis,  so  often  observed  in  puerperal  septicaemia,  does  not  ne- 
cessarily depend  on  the  direct  transmission  of  inflammation  from  the 
pelvic  connective  tissue,  but  is  more  often  a  secondary  phenomenon. 
The  channels  through  which  general  sj^stemic  infection  may  super- 
vene are  the  lymphatics  and  the  venous  sinuses,  the  former  being  by 
far  the  most  important.  Recent  researches  have  shown  the  great 
number  and  complexity  of  the  lymphatics  in  connection  with  the 
pelvic  viscera,  and  marked  traces  of  the  absorption  of  septic  matter 
are  almost  always  to  be  found,  except  in  those  very  intense  cases 
already  alluded  to,  in  which  no  appreciable  post-mortem  signs  are 
discoverable.  The  septic  matter  is  probably  absorbed  from  the 
lymyjh  spaces  abounding  in  the  connective  tissue,  and  carried  along 
the  lymphatic  canals  to  the  nearest  glands.  The  result  is  inflamma- 
tion of  their  coats,  and  thrombosis  of  their  contents,  which  may  be 
seen  on  section  as  a  creamy  purulent  substance.  The  absorption  of 
septic  material  may,  as  Yirchow  has  shown,  be  delayed  by  the  local 
changes  produced  in  the  lymphatics  and  in  the  glands  with  which 
they  communicate,  which  are,  therefore,  conservative  in  their  action  ; 
and  the  fui-ther  ])rogress  of  the  case  may  in  this  way  be  stopped,  and 
local  inflammation  alone  result,  such  cases  being  believed  by  Heiberg 
to  be  examples  of  abortive  pysemia.  On  the  other  hand,  the  free 
septic  material  may  be  too  abundant  and  intense  to  be  so  arrested, 
it  may  pass  on  through  the  lymph  canals  and  glands,  until  it  reaches 
the  blood  current  through  the  thoracic  duct,  and  so  produces  a  gene- 
ral blood-infection.  This  mode  of  absorption  of  septic  matter,  and 
the  tendency  of  the  glands  to  arrest  its  further  progress,  serve  to 
explain  the  progressive  character  of  many  cases,  in  which  fresh 
exacerbations  seem  to  occur  from  time  to  time;  since  fresh  quantities 
of  poison,  generated  at  its  source  of  origin,  may  be  absorbed  as  the 
case  progresses.  The  uterine  veins  are  supposed  by  D'Espinne  to  be 
the  channel  of  absorption  in  the  intense  form  of  disease  which  proves 
fatal  very  shortly  after  delivery,  too  soon  for  the  more  gradual  pro- 
cess of  lymphatic  absorption  to  have  become  established.  It  is  evi- 
dent that  the  veins  are  not  likely  to  act  in  this  way,  since  they  must, 
under  ordinary  circumstances,  be  completelj^  occluded  by  thrombi, 
otherwise  hemorrhage  would  occur.  If,  however,  uterine  conrtaction 
be  incomplete,  the  occlusion  of  the  venous  sinuses  may  be  imperfect, 
and  absorption  of  septic  material  through  them  may  then  take  place. 
Some  writers  have  laid  great  stress  on  imperfect  uterine  contraction 
in  predisposing  to  septiceemia,  and  its  influence  may  thus  be  well 


PUERl'KKAL    SEPTICAEMIA.  603 

explained.  The  veins  may  bear  an  important  part  in  the  production 
of  septicaemia,  independent  of  the  direct  absorption  of  septic  matter 
through  them,  by  means  of  the  detachment  of  minute  portions  of 
their  occluding  thrombi,  in  the  form  of  emboli.  If  phlegmonous 
inflammation  occur  in  the  immediate  vicinity  of  the  veins,  the 
thrombi  they  contain  may  become  infected.  When  once  blood  infec- 
tion has  occurred,  by  any  of  these  channels,  general  septicaemia,  the 
so-called  puerperal  fever,  is  developed. 

Patholoyicai  Phenomena  observed  after  general  Blood-infection. — - 
The  variety  of  pathological  phenomena  found  on  post-mortem  ex- 
amination has  had  much  to  do  with  the  prevalent  confusion  as  to  the 
nature  of  the  disease.  This  has  resulted  in  the  description  of  many 
distinct  forms  of  puerperal  fever  ;  the  most  marked  pathological  alte- 
ration having  been  taken  to  be  the  essential  element  of  the  disease. 
As  a  matter  of  fact  there  is  no  doubt  that  various  types  of  pathologi- 
cal change  are  met  with.  Heiberg  describes  four  chief  classes  which, 
are  by  no  means  distinctly  separated  from  one  another,  are  often 
found  simultaneously  in  the  same  subject,  and  are  certainly  not  to  be 
distinguished  by  the  symptoms  during  life. 

Intense  Gases  luithout  marked  Post-mortem  Signs. — Of  these,  the 
first  is  the  class  of  cases  in  which  no  appreciable  morbid  phenomena 
are  found  after  death.  This  formidable  and  fatal  form  of  the  disease 
has  long  been  well  known,  and  is  that  described  bv  some  of  our 
authors  as  adynamic,  or  malignant  puerperal  fever.  It  is  the  variety 
which  was  so  prevalent  in  our  lying-in  hospital,  and  which  Eams- 
botham  talks  of  as  being  second  only  to  cholera  in  the  severity  and 
suddenness  of  its  onset,  and  in  the  rapidity  with  which  it  carried  oif 
its  victims.  It  is  quite  erroneous  to  suppose  that  the  existence  of 
pathological  changes  in  this  form  of  disease  has  never  been  recog- 
nized. Even  with  the  coarse  methods  of  examination  formerly  used, 
the  occurrence  of  a  fluid  and  altered  state  of  the  blood,  and  ecchy- 
moses  in  connection  with  various  organs — -especially  the  lungs,  spleen, 
and  kidneys — were  noticed  and  specially  described  by  Copland  in 
his  dictionary  of  medicine.  More  recently  it  has  been  clearly  proved 
by  the  microscope  that  there  exist,  in  addition,  the  commencement 
of  inflammation  in  most  of  the  tissues,  shown  bv  cloudy  swellings, 
and  granular  infiltration  and  disintegration  of  the  cell  element's  ; 
proving  that  the  blood,  heavily  charged  with  septic  matter,  had  set 
up  morbid  action  whenever  it  circulated,  the  patient  succumbing 
before  this  had  time  to  develop. 

Gases  Gharacterized  hj  Inflammation  of  the  Serous  Memhranes. — 
In  the  second  type,  and  that  perhaps  most  commonly  met  with,  the 
morbid  changes  are  more  frequently  found  in  the  serous  membranes, 
in  the  pleura,  the  pericardium,  but,  above  all,  in  the  peritoneum,  the 
alterations  in  which  have  long  attracted  notice,  and  have  been  taken 
by  many  writers  as  proving  peritonitis  to  be  the  main  element  of  the 
disease.  Evidences  of  more  or  less  peritonitis  are  very  general.  In 
the  more  severe  cases  there  is  little  or  no  exudation  of  plastic  lymph, 
such  as  is  found  in  peritonitis  unassociated  with  septicemia.  There 
is  a  greater  or  less  quantity  of  brownish  serum  only,  the  coils  of 


604  THE    PUERPERAL    STATE. 

intestine,  distended  with  flatns,  and  higlily  congested,  being  sur- 
rounded by  it.  More  often  there  are  patchy  deposits  of  fibrinous 
exudation  over  many  of  the  viscera,  the  fundus  uteri,  the  under  sur- 
face of  the  liver,  and  the  distended  intestines.  There  is  then  also  a 
considerable  quantity  of  sero-purulent  fluid  in  the  abdominal  cavity. 
The  pleural  cavities  may  also  exhibit  similar  traces  of  inflammatory 
action,  containing  imperfectly  organized  lymph,  and  sero-purulent 
fluid.  Schroeder  states  that  pleurisy  is  more  often  the  direct  result 
of  transmission  of  inflammation  through  the  substance  of  the  dia- 
phragm or  lung,  than  a  secondary  consequence  of  the  septicaimia. 
In  like  manner  evidences  of  pericarditis  may  exist,  the  surface  of  the 
pericardium  being  highly  injected,  and  its  cavity  containing  serous 
fluid.  Inflammation  of  the  synovial  membranes  of  the  larger  joints, 
occasionally  ending  in  suppuration,  is  not  uncommon,  and  may  prob- 
ably be  best  included  under  this  class  of  cases. 

Cases  Characterized  by  changes  in  the  Mucous  Membrane. — In  the 
third  type  the  mucous  membranes  appear  to  bear  the  brunt  of  the 
disease.  The  pathological  changes  are  most  marked  in  the  mucous 
membrane  lining  the  intestines,  which  is  highly  congested  and  even 
ulcerated  in  patches,  with  numerous  small  spots  of  blood  extravasated 
in  the  sub-mucous  tissue.  Similar  small  apoplectic  effusions  have 
been  observed  in  the  substance  of  the  kidneys,  and  under  the  mucous 
membrane  of  the  bladder.  Pneumonia  is  of  common  occurrence. 
In  most  cases  it  is  probably  secondary  to  the  impaction  of  minute 
emboli  in  the  smaller  branches  of  the  pulmonary  artery  ;  but  it  may 
doubtless  arise  from  independent  inflammation  of  the  lung  tissue,  and 
will  then  be  included  in  tlie  class  of  cases  now  under  consideration. 

Cases  Characterized  by  the  Imixiction  of  Infected  Emboli  and  Second- 
ary Inflammation  and  Abscess. — The  fourth  class  of  pathological 
phenomena  are  those  which  are  produced  chiefly  by  the  impaction 
of  minute  infected  emboli  in  small  vessels  in  various  parts  of  the 
body.  These  are  the  cases  which  most  closely  resemble  surgical 
pyaemia,  both  in  their  symptoms  and  post-mortem  signs,  and  which 
by  many  writers  are  described  under  the  name  of  puerperal  pycemia. 
The  dependence  of  puerperal  fever  on  phlebitis  of  the  uterine  veins 
was  a  favorite  theory,  and  in  a  large  proportion  of  cases  the  coats  of 
the  veins  show  signs  of  inflammation,  their  canals  being  occupied 
with  thrombi  in  a  more  or  less  advanced  state  of  disintegration.  The 
mode  in  which  these  thrombi  may  become  infected  has  been  shown 
by  Babnoff,  who  has  proved  that  leucocytes  may  penetrate  the  coats 
of  the  vein,  and  entering  its  contained  coagulum,  may  set  up  disin- 
tegration and  suppuration.  This  observation  brings  these  pysemic 
forms  of  disease  into  close  relation  with  septicaemia,  such  as  we  have 
been  studying,  and  justifies  the  conclusion  of  Yerneuil  that  purulent 
infection  is  not  a  distinct  disease,  but  only  a  termination  of  septi- 
caemia, Avith  which  it  ought  to  be  studied.  We  have,  moreover,  to 
differentiate  these  results  of  embolism  from  those  considered  in  a 
subsequent  chapter ;  the  characteristic  of  these  cases  being  the  in- 
fected nature  of  the  minute  emboli.  Localized  inflammations  and 
abscesses,  from  the  impaction  of  minute  capillary  emboli  are  found 


PUERPERAL    SEPTICEMIA.  605 

in  many  parts  of  the  body ;  most  frequently  in  the  lungs,  then  in 
the  kidneys,  spleen,  and  liver,  and  also  in  the  muscles  and  connective 
tissues.  Pathologists  are  by  no  means  agreed  as  to  the  invariable 
dependence  of  these  on  embolism,  nor  is  it  possible  to  prove  their 
origin  from  this  source  by  post-mortem  examination.  Sjme  attri- 
bute all  such  cases  to  embolism,  others  think  that  they  may  be  the 
results  of  primary  septicyemic  inflammation.  It  has  been  proved  by 
Weber  that  minute  infested  emboli  may  pass  through  the  lung- 
capillaries  ;  and  this  disposes  of  one  argument  against  the  embolic 
theory,  based  on  the  supposed  impossibility  of  their  passage.  It  is 
probable  that  both  causes  may  operate,  and  that  localized  inflamma- 
tions occurring  a  short  time  after  delivery  are  directly  produced  by 
the  infected  blood,  while  those  occurring  after  the  lapse  of  sometime, 
as  in  the  second  or  third  week,  depend  upon  embolism. 

Description  of  the  Disease. — From  what  has  been  said  as  to  the 
mode  of  infection  in  puerperal  septictemia,  and  as  to  the  very  various 
pathological  changes  which  accompany  it,  it  will  not  be  a  matter  of 
surprise  to  find  that  the  symptoms  are  also  very  various  in  different 
cases.  This  can  readily  be  explained  by  the  amount  and  virulence 
of  the  poison  absorbed,  the  channels  of  infection,  and  the  organs 
which  are  chiefly  implicated;  but  it  renders  it  very  difhcuit  to 
describe  the  disease  satisfactorily. 

The  symptoms  generally  show  themselves  within  two  or  three 
days  after  delivery.  As  infection  most  often  occurs  during  labor, 
or,  in  cases  which  are  autogenetic,  within  a  short  time  afterwards, 
and  before  the  lesions  of  continuity  in  the  generative  tract  have 
commenced  to  cicatrize,  it  can  be  understood  why  septiccemia  rarely 
commences  later  than  the  fourth  or  fifth  day. 

In  the  great  majority  of  cases  the  disease  begins  insidiously.  There 
are,  generally,  some  chilliness  and  rigor,  but  by  no  means  always, 
and  even  when  present  they  frequently  escape  observation,  or  are 
referred  to  some  transient  cause.  The  first  symptom  which  excites 
attention  is  a  rise  in  the  pulse,  which  may  vary  from  100  to  l-iO  or 
more,  according  to  the  severity  of  the  attack ;  and  the  thermometer 
will  also  show  that  the  temperature  is  raised  to  102°,  or,  in  bad 
cases,  even  to  104°  or  106°.  Still,  it  must  be  borne  in  mind  that 
both  the  pulse  and  temperature  xnsij  be  increased  in  the  puerperal 
state  from  transient  causes,  and  do  not,  of  themselves,  justify  the 
diagnosis  of  septicaemia. 

/Symptoms  of  Intense  Septicsemia. — In  the  more  intense  class  of 
cases,  in  which  the  whole  system  seems  overwhelmed  with  the 
severity  of  the  attack,  the  disease  progresses  with  great  rapidity, 
and  often  without  any  appreciable  indication  of  local  complication. 
The  pulse  is  very  rapid,  small,  and  feeble,  varying  from  120  to  140, 
and  there  is  generally  a  temperature  of  103°  or  104°.  There  may 
be  little  or  no  pain,  or  there  may  be  slight  tenderness  on  pressure 
over  the  abdomen  or  uterus;  and,  as  the  disease  progresses,  the 
intestines  get  largely  distended  with  flatus,  so  that  intense  tympanites 
often  form  a  most  distressing  symptom.  The  countenance  is  sallow, 
sunken,  and  has  a  very  anxious  expression.     As  a  rule,  intelligence 


606  THE    PUERPERAL    STATE. 

is  unimpaired,  and  this  may  be  the  case  even  in  the  worst  forms  of 
the  disease,  and  up  to  the  period  of  death.  At  other  times,  there  is 
a  good  deal  of  low  muttering  delirium,  which  often  occurs  at  night 
alone,  and  alternates  with  intervals  of  complete  consciousness,  but 
is  occasionally  intensified,  for  a  short  time,  into  a  more  acute  form. 
Diarrhoea  and  vomiting  are  of  very  frequent  occurrence ;  by  the 
latter  dark,  grumous,  coffee-ground  substances  are  ejected.  The 
diarrhoea  is  occasionally  very  profuse  and  uncontrollable;  in  mild 
cases  it  seems  to  relieve  the  severity  of  the  symptoms.  The  tongue 
is  moist  and  loaded  with  sordes;  but  sometimes  it  gets  dark  and  drj^, 
especially  towards  the  termination  of  the  disease.  The  lochia  are 
generally  suppressed,  or  altered  in  character,  and  sometimes  they 
have  a  highly  offensive  odor,  especially  when  the  disease  is  auto- 
genetic.  The  breathing  is  hurried  and  panting,  and  the  breath 
itself  has  a  very  characteristic,  heavy,  sweetish  odor.  The  secretion 
of  milk  is  often,  but  not  always,  arrested. 

Duration  of  the  Disease. — Yfith  more  or  less  of  these  symptoms 
the  case  goes  on ;  and  when  it  ends  fatally  it  generally  does  so  within 
a  week,  the  fatal  termination  being  indicated  by  more  weakness, 
rapid,  threadlike,  or  intermittent  pulse,  marked  delirium,  great  tym- 
panites, and  sometimes  a  sudden  fall  of  temperature,  until  at  last  the 
patient  sinks  with  all  the  symptoms  of  profound  exhaustion. 

Variety  of  Symptoms  in  Different  Cases. — In  milder  cases  similar 
symptoms,  variously  modified  and  combined  are  present.  It  is 
seldom  that  two  precisely  similar  cases  are  met  with  ;  in  some,  the 
rapid,  weak  pulse  is  most  marked ;  in  others,  abdominal  distension, 
vomiting,  diarrhoea,  or  delirium. 

Symptoms  of  Peritonitis. — Local  complications  variously  modify 
the  symptoms  and  course  of  the  disease.  The  most  common  is  peri- 
tonitis, so  much  so  that  with  some  authors  puerperal  fever  and  puer- 
peral peritonitis  are  synonymous  terms.  Here  the  first  symptom  is 
severe  abdominal  pain,  commencing  at  the  lower  part  of  the  abdomen, 
where  the  uterus  is  felt  enlarged  and  tender.  As  the  abdominal  pain 
and  tenderness  spread,  the  sufferings  of  the  patient  greatly  increase, 
the  intestines  become  enormously  distended  with  flatus,  and  the 
breathing  is  entirely  thoracic,  in  consequence  of  the  upward  dis- 
placement of  the  diaphragm  and  the  fact  that  the  abdominal  muscles 
are  instinctively  kept  as  much  in  repose  as  possible.  The  patient 
lies  on  her  back,  with  her  knees  drawn  up,  and  sometimes  cannot 
bear  the  slightest  pressure  of  the  bedclothes.  There  is  generally 
much  vomiting,  and  often  severe  diarrhoea.  The  temperature  gener- 
ally ranges  fro'm  102"  to  104°,  or  even  106°,  and  is  subject  to  occa- 
sional exacerbations  and  remissions,  possibly  depending  on  fresh 
absorption  of  septic  matter.  The  case  generally  lasts  for  a  week  or 
more,  the  symptoms  going  on  from  bad  to  worse,  and  the  patient 
dying  exhausted.  D'iEspinne  points  out  that  rigors,  with  exacerba- 
tfons  of  the  general  symptoms,  not  unfrequently  occur  about  the 
sixth  or  seventh  day,  which  he  attributes  to  fresh  systemic  infection, 
from  fetid  pus  in  the  peritoneal  cavity.  It  must  not  be  supposed 
that  all  these  symptoms  are  necessarily  present  when  the  peri  tonic 


PUERPERAL    SEPTICiEMIA.  607 

complication  exists.  Pain  especially  is  often  entirely  absent,  and  I 
have  seen  cases  in  which  post-mortem  examination  proved  tlie  exist- 
ence of  peritonitis  in  a  very  marivcd  degree,  in  which  pain  was  en- 
tirely absent.  Sometimes  the  pain  is  only  slight,  and  amounts  to 
little  more  than  tenderness  over  the  uterus. 

Other  local  complications  are  characterized  by  their  own  special 
symptoms;  thus  pneumonia  by  dyspnoea,  cough,  dulness,  etc.;  peri- 
carditis by  the  characteristic  rub;  pleurisy  by  dulness  on  percussion; 
kidney  affection  by  albuminuria  and  the  presence  of  casts  ;  liver  com- 
plication by  jaundice  ;  and  so  on. 

Pyxmic  Forms  of  the  Disease. — The  course  of  the  disease  is  not 
always  so  intense  and  rapid,  being,  in  some  cases,  of  a  more  chronic 
character,  and  lasting  many  weeks.  The  symptoms  in  the  early 
stage  are  often  indistinguishable  from  those  already  described ;  and 
it  is  generally  only  after  the  second  week,  that  indications  of  purulent 
infection  develop  themselves.  Then  we  often  have  recurrent  and 
very  severe  rigors,  with  marked  elevations  and  remissions  of  tempe- 
rature. At  the  same  time  there  is  generally  an  exacerbation  of  the 
general  symptoms,  a  peculiar  yellowish  discoloration  of  the  skin,  and 
occasionally  well-developed  jaundice.  Transient  patches  of  erythema 
are  not  uncommonly  observed  on  various  parts  of  the  skin,  and  such 
eruptions  have  often  been  mistaken  for  those  of  scarlet  fever  or  other 
zymotic  disease.  Localized  inflammations  and  suppuration  may 
rapidly  follow.  Amongst  the  most  common  are  inflammation  or 
even  suppuration  of  the  joints — the  knees,  shoulders,  or  hips — which 
is  preceded  by  difficulty  of  movement,  swelling,  and  very  acute  pain 
Large  collections  of  pus  in  various  parts  of  the  muscles  and  connect- 
ive tissues  are  not  rare.  Suppurative  inflammation  may  also  be 
found  in  connection  with  many  organs,  as  in  the  eye,  in  the  pleura, 
pericardium,  or  lungs:  each  of  which  will,  of  course,  give  rise  to 
characteristic  symptoms,  more  or  less  modified  by  the  type  of  the 
disease  and  the  intensity  of  the  inflammation. 

Treatment.— \\x  considering  the  all-important  subject  of  treatment, 
the  views  of  the  practitioner  are  naturally  biased  by  the  theory  he 
has  adopted  of  the  nature  of  the  disease.  If  that  here  inculcated  be 
correct,  the  indications  we  have  to  bear  in  mind  are  ;  1st,  to  discover, 
if  possible,  the  source  of  the  poison,  in  the  hope  of  arresting  farther 
septic  absorption ;  2d,  to  keep  the  patient  alive  until  the  effects  of 
the  poison  are  worn  off;  and  3d,  to  treat  any  local  complications 
that  may  arise. 

The  tlse  of  Antisejjtic  Injections. — ^The  first  is  likely  to  be  of  great 
importance  in  cases  of  self-infection,  as  fresh  quantities  of  seyjtic  mat- 
ter may  be,  from  time  to  time,  absorbed.  We,  fortunately,  are  in 
possession  of  a  powerful  means  of  preventing  further  absorption  by 
the  application  of  antiseptics  to  the  interior  of  the  uterus,  and  to  the 
canal  of  the  vagina.  This  is  especially  valuable  when  the  existence 
of  decomposing  coagula,  or  other  sources  of  septic  matter,  is  sus- 
pected in  the  uterine  cavity,  or  when  offensive  discharges  are  present. 
Disinfection  is  readily  accomplished  by  washing  out  the  uterine 
cavity,  at  least  twice  daily,  by  means  of  a  Higginson's  syringe  with 


608 


THE    PUERPERAL    STATE. 


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'l-v.,  .I'kl 

a  long  vaginal  pipe  attached.^  The  results  are  sometimes  very  re- 
markable, the  threatening  symptoms  rapidly  disappearing,  and  the 
temperature  and  pulse  falling  so  soon  after  the  use  of  the  antiseptic 

injections  as  to  leave  no  doubt  of  the 
beneficial  effects  of  the  treatment." 
I  cannot  better  illustrate  the  advan- 
tages of  this  treatment  than  by  the 
accompanying  temperature  chart, 
which  is  from  a  case  which  came 
under  my  observation  in  the  out-door 
practice  of  King's  College  Hospital. 
It  was  that  of  a  healthy  woman, 
thirty- six  years  of  age,  who  had  an 
easy  and  natural  labor.  Nothing  re- 
markable was  observed  until  the  3d 
day  after  delivery,  when  the  temper- 
ature was  found  to  be  slightly  in- 
creased. On  the  morning  of  the  8th  day  the  temperature  had  risen 
to  105.4°.  She  was  delirious,  with  a  rapid  thready  pulse,  clammy 
perspiration,  tympanitic  abdomen,  and  her  general  condition  indicated 
the  most  urgent  danger.  On  vaginal  examination  a  piece  of  com- 
pressed and  putrid  placenta  was  found  in  the  os.  This  was  removed 
by  my  colleague.  Dr.  Hayes,  and  the  uterus  thoroughly  washed  out 
with  Condy's  fluid  and  Avater.  The  same  evening  the  temperature 
had  sunk  to  99°  and  the  general  symptoms  were  much  improved. 
The  next  day  there  was  a  slight  return  of  offensive  discharge,  and 
an  aggravation  of  the  symptoms.  After  again  washing  out  the 
uterus  the  temperature  fell,  and  from  that  date  the  patient  conva- 
lesced without  a  single  bad  symptom. 

This  is  a  very  well-marked  example  of  the  value  of  local  anti- 
septic treatment,  and  I  have  seen  many  cases  of  the  same  kind.  It 
should,  therefore,  never  be  omitted  in  all  cases  in  which  self-infection 
is  possible ;  and,  indeed,  even  when  there  is  no  reason  to  suspect  the 
presence  of  a  local  focus  of  infection,  the  use  of  antiseptic  lotions  is 

•  My  colleague,  Di-.  Hayes,  has  invented  a  silver  tube  for  the  purpose  of  adminis- 
tering such  iutra-uterine  injections  (Fig.  183),  which  answers  its  purpose  admirably. 

Fig.  183. 


Hayes's  Tube  for  Tntra-uterine  Injections. 

The  numerous  apertures  at  its  extremity  allow  of  a  number  of  minute  streams  of  fluid 
being  thrown  out  in  the  form  of  a  spray  over  the  interior  of  the  uterus,  the  complete 
bathing  of  its  surface  and  washing  out  of  its  cavity  being  thus  insured.  It  is,  more- 
over introduced  more  easily  than  the  ordinary  vaginal  pipe,  and  can  be  attached  to  a 
Higginson  syringe. 


PUERPERAL    SEPTIC^xMIA.  609 

advisable,  as  a  matter  of  precaution,  since  it  can  do  no  harm,  and  is 
generally  comforting  to  the  patient.  Any  antiseptic  may  be  used, 
such  as  a  weak  solution  of  carbolic  acid,  1  in  oO,  or  of  tincture  of 
iodine,  or  Condy's  fluid  largely  diluted.  I  generally  use  the  two  latter 
alternately,  the  one  in  the  morning,  the  other  in  the  evening.  The 
nozzle  of  the  syringe  should  be  guided  well  through  the  cervix,  and 
the  cavity  of  the  uterus  thoroughly  washed  out,  until  the  fluid  that 
issues  from  the  vagina  is  no  longer  discolored.  As  the  os  is  always 
patulous,  there  is  no  risk  of  producing  the  troublesome  symptoms  of 
uterine  colic  which  occasionally  follow  the  use  of  intra-uterine  injec- 
tions in  the  unimpregnated  state.  It  is  quite  useless  to  entrust  the  injec- 
tion to  the  nurse,  and  it  should  be  performed  at  least  twice  daily  by  the 
practitioner  himself,  in  all  cases  in  which  the  discharges  are  offensive. 
Administration  of  Food  and  Stimulants. — In  a  disease  characterized 
by  so  marked  a  tendency  to  prostration,  the  importance  of  sustaining 
the  vital  powers  by  an  abundance  of  easily  assimilated  nourishment 
cannot  be  overrated.  Strong  beef-tea,  or  other  forms  of  animal  soup, 
milk,  alone  or  mixed  either  with  lime  or  soda  water,  and  the  yolk  of 
eggs,  beat  up  with  milk  and  brandy,  should  be  given  at  short  inter- 
vals, and  in  as  large  quantities  as  the  patient  can  be  induced  to  take; 
and  the  value  of  thoroughly  eflEicient  nursing  will  be  specially  ap- 
parent in  the  management  of  this  important  part  of  the  treatment. 
As  there  is  frequently  a  tendency  to  nausea,  the  patient  may  resist 
the  administration  of  food,  and  the  resources  of  the  practitioner  will 
be  taxed  in  administering  it  in  such  form  and  variety  as  will  prove 
least  distasteful.  Generally  speaking  not  more  than  one  or  two 
hours  should  be  allowed  to  elapse  without  some  nutriment  being 
given.  The  amount  of  stimulant  required  will  vary  with  the  inten- 
sity of  the  symptoms,  and  the  indications  of  debility.  Generally, 
stimulants  are  well  borne,  prove  decidedly  beneficial,  and  require  to 
be  given  pretty  freely.  In  cases  of  moderate  severity  a  tablespoonful 
of  good  old  brandy  or  whiskey  every  four  hours  may  suffice ;  but 
when  the  pulse  is  very  rapid  and  thready,  when  there  is  much  low 
delirium,  tympanites,  or  sweating  (indicating  profound  exhaustion), 
it  may  be  advisable  to  give  them  in  much  larger  quantities  and  at 
shorter  intervals.  The  careful  practitioner  will  closely  watch  the 
effects  produced,  and  regulate  the  amount  by  the  state  of  the  patient, 
rather  than  by  any  fixed  rule ;  but  in  severe  cases,  eight  or  twelve 
ounces  of  brandy,  or  even  more,  in  the  twenty-four  hours  may  be 
given  with  decided  benefit. 

Venesection  not  Admissible} — Venesection,  both  general  and  local, 

['  I  believe  that  the  entire  abandonment  of  venesection  has  been  a  grave  error,  and 
that  where  there  is  early  in  the  attack,  a  high  pnlse,  with  great  abdominal  distension 
and  tenderness,  and  a  decided  elevation  of  temperature,  we  ought  to  bleed  the  patient 
sitting,  at  once,  and  to  such  a  degree  as  to  i^roduce  a  decided  impression.  One  of  the 
worst  cases  I  ever  saw,  was  cured  in  this  way.  The  woman  was  delivered  at  3^  P.M. 
of  one  day,  and  the  disease  manifested  itself  in  twenty  hours.  At  9  the  next  morning 
she  was  apparently  doing  well :  at  1  she  was  in  great  suffering,  and  could  not  bear 
her  abdomen  to  be  touched  ;  vs.  i§xvj  :  at  9  P.M.,  symptoms  more  grave  ;  vs.  ffxl  in 
a  sitting  posture  until  she  felt  sick.  At  10  P.  M.  pulse  150 :  in  twenty-four  hours  from 
this,  no  fever  and  very  little  pain  :  in  three  days,  regarded  as  out  of  danger.  Saw 
her  in  robust  health,  with  her  child  living,  a  year  later. — Ed. J 


610  THE    PUERPERAL    STATE. 

was  long  considered  a  sheet  anchor  in  this  disease.  Modern  views 
are,  however,  entirely  opposed  to  its  nse ;  and  in  a  disease  character- 
ized by  so  profound  an  alteration  of  the  blood,  and  so  much  prostra- 
tion, it  is  too  dangerous  a  remedy  to  employ,  although  it  is  possible 
that  it  might  alleviate  temporarily  the  severity  of  some  of  the 
symptoms,  especially  in  cases  in  which  peritonitis  is  well  marked,  and 
much  local  pain  and  tenderness  are  present. 

Medicinal  Treatment. — The  rational  indications  in  medicinal  treat- 
ment are  to  lessen  the  force  of  the  circulation  as  much  as  is  possible 
without  favoring  exhaustion;  and  to  diminish  the  temperature. 

Use  of  Arterial  Sedatives. — For  the  former  purpose.  Barker  strongly 
advocates  the  use  of  veratrum  viride,  in  doses  of  five  drops  of  the 
tincture  every  hour,  until  the  pulse  falls  to  below  100,  when  its 
effects  are  subsequently  kept  up  by  two  or  three  drops  every  second 
hour.  Of  this  drug  I  have  no  personal  experience;  but  I  have  ex- 
tensively used  minute  doses  of  tincture  of  aconite  for  the  same  pur- 
pose, and,  when  carefully  given,  I  believe  it  to  be  a  most  valuable 
remedy.  The  way  I  have  administered  it  is  to  give  a  single  drop  of 
the  tincture,  at  first  every  half-hour,  increasing  the  interval  of  ad- 
ministration according  to  the  effect  produced.  Generally,  after  giving 
four  or  five  doses  at  intervals  of  half  an  hour,  the  pulse  begins  to 
fall,  and  afterwards  a  few  doses,  at  intervals  of  one  or  two  hours, 
will  suffice  to  prevent  the  heart's  action  rising  to  its  former  rapidity. 
The  advantage  of  thus  modifying  cardiac  action,  with  the  vicAV  of 
preventing  excessive  waste  of  tissue,  cannot  be  questioned.  It  is 
evident  that  so  powerful  a  remedy  m\ist  not  be  used  without  the 
most  careful  supervision,  for,  if  continued  too  long,  or  given  at  too 
frequent  intervals,  it  may  unduly  depress  the  circulation,  and  do 
more  harm  than  good.  It  is  necessary,  therefore,  that  the  practi- 
tioner should  constantly  watch  the  effect  of  the  drug,  and  stop  it  if 
the  pulse  become  very  weak,  or  if  it  intermit.  It  is  most  likely  to 
be  useful  at  an  early  stage  of  the  disease  before  much  exhaustion  is 
present,  and  then  only  when  the  pulse  is  of  a  certain  force  and 
volume.  Barker  says  of  the  veratrum  viride,  what  is  also  true  of 
aconite,  that  "it  should  not  be  given  in  those  cases  in  which  rapid 
prostration  is  manifested  by  a  feeble,  thread-like  irregular  pulse, 
profuse  sweats,  and  cold  extremities." 

Reduction  of  Temperature. — The  reduction  of  temperature  must 
form  an  important  part  of  our  treatment,  and  for  this  purpose  many 
agents  are  at  our  disposal. 

Quinine  in  large  doses,  of  from  10  to  20  grains,  has  been  much 
used  for  this  purpose,  especially  in  Grermany,  After  its  exhibition 
the  temperature  frequentlv  falls  one  or  two  degrees.  It  may  be  given 
morning  and  evening.  Unpleasant  head-symptoms,  deafness,  and 
ringing  in  the  ears,  often  render  its  continuance  for  a  length  of  time 
impossible;  these  may,  however,  be  much  lessened  by  the  addition 
of  10  to  15  minims  of  hydrobromic  acid  to  each  dose. 

Salicylic  acid^  in  doses  of  from  10  to  20  grains,  or  the  salicylate  of 
soda  in  the  same  doses,  is  a  valuable  antipyretic,  which  I  have  found 


PUERPERAL    SEPTICAEMIA.  611 

on  the  whole  more  manageable  than  quinine.  Under  its  use  the 
temperature  often  falls  considerably  in  a  short  space  of  time.  It  is, 
however,  apt  to  depress  the  circulation,  and  thus  requires  to  be  care- 
fully watched  while  it  is  being  administered,  and  should  the  pulse 
become  very  small  and  feeble,  it  should  be  discontinued. 

Warhurr/s  Tincture. — In  some  cases,  especially  when  the  fever  has 
assumed  a  remittent  type,  I  have  administered  with  marked  benefit, 
a  drug  which  is  of  high  repute  in  India,  in  the  worst  class  of  mala- 
rious remittent  fevers,  and  the  almost  marvellous  effects  of  which  in 
such  cases  I  had  myself  witnessed  in  India  many  years  ago.  This  is 
the  so-called  AVarburg's  tincture,  the  value  of  which  has  been  testified 
to  by  many  high  authorities;  among  whom  I  may  mention  Dr.  Mac- 
lean of  Netley,  Dr.  Broadbent,  and  Sir  Alexander  Armstrong,  the 
Director-General  of  the  Medical  Department  of  the  Navy,  who  informs 
me  that  it  is  now  supplied  to  all  Pier  Majesty's  ships  in  the  tropics, 
because  it  is  found  to  be  of  the  utmost  value  in  cases  in  which  quinine 
has  little  or  no  effect. 

Escently  its  composition  has  been  made  public  by  Dr.  Maclean. 
The  basis  is  quinine,  in  combination  with  various  aromatics  and  bit- 
ters, some  of  which  probabl}'-  intensify  its  action.  Be  this  as  it  may, 
the  testimony  in  favor  of  the  anti-pyretic  action  of  the  remedy  is 
very  strong.  I  have  found  its  exhibition  followed  by  a  profuse  dia- 
phoresis (this  being  its  almost  invariable  effect),  and  sometimes  a 
rapid  amelioration  of  the  symptoms.  In  other  cases  in  which  I  have 
tried  it,  like  everything  else,  it  has  proved  of  no  avail. 

Aj^plication  of  Gold. — Cold  may  be  advantageously  tried  in  suitable 
cases.  The  simplest  mode  of  using  it  is  by  Thornton's  ice-cap,  by 
which  a  current  of  cold  water  is  kept  continuously  running  round 
the  head.  This  has  been  found  of  great  value  in  pyrexia  after  ova- 
riotomy, and  I  have  also  found  it  useful  as  a  means  of  reducing  tem- 
perature in  puerperal  cases.  It  is  a,comforting  application,  and  gives 
great  relief  to  the  throbbing  headache,  which  often  causes  much  suf- 
fering. Under  its  use  the  temperature  often  falls  two  or  more  de- 
grees, and  it  is  easily  continued  day  or  night. 

In  very  serious  cases,  when  the  temperature  reaches  105°  and  up- 
wards, the  external  application  of  cold  to  the  rest  of  the  body  may 
be  tried.  I  have  elsewhere  related  a  case  of  puerperal  septicemia 
with  hyper-pyrexia,  the  temperature  continuously  ranging  over  105°, 
in  which  I  kept  the  patient  for  eleven  days^  nearly  continuously 
covered  with  cloths  soaked  in  iced  water,  by  which  means  only  was 
the  temperature  kept  within  moderate  bounds,  and  life  preserved. 
But  this  method  of  treatment  is  excessively  troublesome,  and  is  in 
no  way  curative.  It  is  only  of  use  in  moderating  the  tempierature 
when  it  has  reached  a  point  at  which  it  could  not  continue  long  with- 
out destroying  the  patient.  I  should,  therefore,  never  think  of  em- 
ploying it  unless  the  temperature  was  over  105°,  and  then  only  as  a 
temporary  expedient,  requiring  incessant,  watching,  to  be  desisted 

'  A  Lecture  on  a  case  of  Puerperal  Septicoemia,  with  Hyper-pyrexia,  treated  by 
the  continuous  application  of  Cold. — Brit.  Med.  Jouni.,  Nov.  17,  1877. 


612  THE    PUERPERAL    STATE. 

from  as  soon  as  the  temperature  had  reached  a  more  moderate  height. 
It  is  clearly  impossible  to  place  a  puerperal  patient  in  a  bath,  as  is 
practised  in  hjper-pyrexia  associated  with  acute  rheumatism.  The 
same  effect  may,  however,  be  obtained  by  placing  her  on  Mackintosh 
sheeting,  and  covering  the  body  with  towels  soaked  in  iced  water, 
which  are  frequently  renewed  by  the  attendant  nurses.  Daring  the 
application  the  temperature  should  be  constantly  taken,  and  as  soon 
as  it  has  fallen  to  101°,  the  cold  applications  should  be  discontinued. 

Administration  of  Tuvpentine. — Amongst  other  remedies  which 
have  been  used  is  turpentine,  which  was  highly  thought  of  by  the 
Dublin  school.  In  cases  with  much  tympanitic  distension,  and  a 
small  weak  pulse,  it  is  sometimes  of  unquestionable  value,  and  it 
probably  acts  as  a  strong  nervine  stimulant.  Given  in  doses  of  15 
to  20  minims,  rubbed  up  with  mucilage,  it  can  generally  be  taken  in 
spite  of  its  nauseous  taste. 

Evacuant  Remedies. — Purgatives,  diaphoretics,  or  even  emetics, 
have  often  been  employed  as  eliminants  of  the  poison.  The  former 
are  strongly  recommended  by  Schroeder  and  other  German  authori- 
ties, and  in  this  country  they  were  formerly  amongst  the  most 
favorite  remedies,  and  there  is  a  general  concurrence  of  opinion 
amongst  our  older  writers  as  to  their  value.  In  the  first  volume  of 
the  "  Obstetrical  Journal,"  there  is  a  paper  by  Mr.  Morton,  in  which 
this  practice  is  strongly  advocated,  and  some  interesting  cases  are 
recorded  in  which  it  apparently  acted  well.  He  administers  calomel 
in  doses  of  3  or  4  grains  with  compound  extract  of  colocynth,  so  as 
to  keep  up  a  free  action  of  the  bowels.  It  seems  quite  reasonable, 
when  there  is  constipation,  to  promote  a  gentle  action  of  the  bowels 
by  some  mild  aperient ;  but,  bearing  in  mind  that  severe  and  ex- 
hausting diarrhoea  is  a  common  accompaniment  of  the  disease,  I 
should  myself  hesitate  to  run  the  risk  of  inducing  it  artificially,  espe- 
cially as  there  is  no  proof  whatever  that  septic  matter  can  really  be 
eliminated  in  this  way.  At  the  commencement  of  the  disease,  how- 
ever, I  have  often  given  one  or  two  aperient  doses  of  calomel  with 
decided  benefit. 

Internal  Antiseptic  Reviedies. — It  is  possible  that  further  research 
will  give  us  some  means  of  counteracting  the  septic  state  of  the  blood, 
and  the  sulphites  and  carbolates  have  been  given  for  this  purpose, 
but  as  yet  with  no  reliable  results. 

Tincture  of  PercMoride  of  Iron. — The  tincture  of  the  perchloride 
of  iron  naturally  suggests  itself,  from  its  well-known  effects  in  surgi- 
cal pyaemia.  In  the  less  intense  forms  of  the  disease,  especially  when 
local  suppurations  exist,  it  is  certainly  useful,  and  may  be  given  iu 
doses  of  10  to  20  minims  every  3  or  4  hours.  In  very  acute  cases 
other  remedies  are  more  reliable,  and  the  iron  has  the  disadvantage 
of  not  unfrequently  causing  nausea  or  vomiting. 

Opiates. — When  restlessness,  irritation,  and  want  of  sleep  are 
prominent  symptoms,  sedatives  may  be  required.  Under  such  cir- 
cumstances opiates  may  be  given  at  night,  and  Battley's  solution, 
nepenthe,  or  the  hypodermic  injection  of  morphia,  are  the  forms 
which  answer  best. 


PUERPERAL    VENOUS    THROMBOSIS    AND    EMBOLISM.  613 

Trea.tm,ent  of  Local  CompUcations. — Pain  and  tenderness,  and  local 
complications,  must  be  treated  on  general  principles.  The  distress 
from  them  is  most  experienced  wlien  peritonitis  is  well  marked. 
Then  warm  and  moist  applications,  in  the  form  of  poultices  or  fomen- 
tations, are  very  useful.  Kelief  is  also  sometimes  cJljtaiued  from 
turpentine  stupes,  and,  when  the  tympanites  is  distressing,  turpentine 
enemata  are  very  serviceable.  I  have  found  the  free  application 
over  the  abdomen  of  the  flexible  collodium  of  the  pharmacopoeia 
decidedly  useful  in  alleviating  the  suffering  from  peritonitis. 

Such  are  the  remedies  most  used  in  the  treatment  of  this  disease. 
It  is  needless  to  say  that  it  is  quite  impossible  to  lay  down  fixed  rules 
for  the  management  of  any  individual  case;  and  it  is  obvious  that, 
if  puerperal  septicasmia  be  not  a  special  and  distinct  disease,  its  judi- 
cious management  must  depend  on  the  general  knowledge  of  the 
attendant,  and  on  a  careful  study  of  the  symptoms  each  separate  case 
presents. 


CHAPTER  VI. 

PUERPERAL  VENOUS  THROMBOSIS  AND  EMBOLISM. 

Under  the  head  of  ihrorabosis  we  may  class  several  important 
diseases  connected  with  the  puerpei'al  state,  which  have  received  far 
less  attention  than  they  deserve.  It  is  only  of  late  years  that  some,  Ave 
may  probably  safely  say  the  majority,  of  those  terribly  sudden  deaths 
which  from  time  to  time  occur  after  delivery,  have  been  traced  to 
their  true  cause,  viz.,  obstruction  of  the  right  side  of  the  heart  and 
pulmonary  arteries  from  a  blood-clot,  either  carried  from  a  distance, 
or,  as  I  shall  hope  to  show,  formed  in  situ.  Although  the  result, 
and,  to  a  great  extent,  the  symptoms,  are  identical  in  both,  still  a 
careful  consideration  of  the  history  of  these  two  classes  of  cases  tends 
to  show  that  in  their  causation  they  are  distinct,  and  that  they  ought 
not  to  be  confounded.  In  the  former,  we  have  primarily  a  clotting 
of  blood  in  some  part  of  the  peripheral  venous  system,  and  the  sepa- 
ration of  a  portion  of  such  a  thrombus  duo  to  changes  undergone 
during  retrograde  metamorphosis  tending  to  its  eventual  absorption. 
In  the  latter  we  have  a  local  deposition  of  flbrine,  the  result  of  blood 
changes  consequent  on  pregnancy  and  the  puerperal  state.  The 
formation  of  such  a  coagulum  in  vessels,  the  complete  obstruction 
of  which  is  incompatible  with  life,  explains  the  fatal  results.  When, 
however,  a  coagulum  chances  to  be  formed  in  more  distant  parts  of 
the  circulation,  the  vital  functions  are  not  immediately  interfered 
with,  and  Ave  have  other  phenomena  occurring,  due  to  the  obstruction. 
The  disease  knoAvn  as  phlegmasia  dolens,  I  shall  presently  attempt 


614  THE    PUERPERAL    STATE. 

to  show,  is  one  result  of  blood-clot  forming  in  peripheral  vessels. 
But  from  the  evident  and  tangible  symptoms  it  produces  it  has  long 
been  considered  an  essential  and  special  disease,  and  the  general 
blood  dyscrasia  which  produces  it,  as  well  as  other  allied  states,  has 
not  been  studied  separately.  I  shall  hope  to  show  that  all  these 
various  conditions,  dissimilar  as  they  at  first  sight  appear,  are  very 
closely  connected,  and  that  they  are  in  fact  due  to  a  common  cause; 
and  thus,  I  think,  we  shall  arrive  at  a  clearer  and  more  correct  idea 
of  their  true  nature,  than  if  we  looked  upon  them  as  distinct  and 
separate  aft'ections,  as  has  been  commonly  done.  I  am  aware  that 
in  phlegmasia  dolens,  the  pathology  of  which  has  received  perhaps 
more  study  than  that  of  almost  any  other  puerperal  affection,  some- 
thing beyond  simple  obstruction  of  the  venous  system  of  the  affected 
limb  is  probably  required  to  account  for  the  peculiar  tense  and 
shining  swelling  which  is  so  characteristic.  Whether  this  be  an 
obstruction  of  the  lymphatics,  as  Dr.  Tilbury  Fox  and  others  have 
maintained  with  much  show  of  reason,  or  whether  it  is  some  as  yet 
undiscovered  state,  further  investigation  is  required  to  show.  But 
it  is  beyond  any  doubt  that  the  important  and  essential  part  of  the 
disease  is  the  presence  of  a  thrombus  in  the  vessels;  and  I  think  it 
will  not  be  difficult  to  prove  that  in  its  causation  and  history  it  is 
precisely  similar  to  the  more  serious  cases  in  which  the  pulmonary 
arteries  are  involved. 

It  will  be  well  to  commence  the  study  of  the  subject  by  a  consid- 
eration of  the  conditions  which,  in  the  puerperal  state,  render  the 
blood  so  peculiarly  liable  to  coagulation,  and  we  may  then  proceed 
to  discuss  the  symptoms  and  results  of  the  formation  of  coagula  in 
various  parts  of  the  circulatory  system. 

Conditions  which  favor  Thrombosis. — The  researches  of  Virchow, 
Benj.  Ball,  Humphrey,  Eichardson,  and  others,  have  rendered  us 
tolerably  familiar  with  the  conditions  which  favor  the  coagulation 
of  the  blood  in  the  vessels.  These  are  chiefly :  1.  A  stagnant  or 
arrested  circulation  ;  as,  for  example,  when  the  blood  coagulates  in 
the  veins  which  draw  blood  from  the  gluteal  region  in  old  and  bed- 
ridden people,  or  as  in  some  forms  of  pulmonary  thrombosis,  in  which 
the  clots  in  the  arteries  are  probably  the  result  of  obstruction  in  the 
circulation  through  the  lung-capillaries,  as  in  certain  cases  of  emphy- 
sema, pneumonia,  or  pulmonary  apoplexy.  2.  A  mechanical  obstruc- 
tion around  wliich  coagula  form,  as  in  certain  morbid  states  of  the 
vessels,  or,  a  better  example  still,  secondary  coagula  which  form 
around  a  travelled  embolus  impacted  in  the  pulmonary  arteries.  3. 
And  most  important  of  all,  in  which  the  coagulation  is  the  result  of 
some  morbid  state  of  the  blood  itself.  Examples  of  this  last  condi- 
tion are  frequently  met  with  in  the  course  of  various  diseases,  such 
as  rheumatism  or  fever,  in  which  the  quantity  of  fibrine  is  increased, 
and  the  blood  itself  is  loaded  with  morbid  material.  Thrombosis 
from  this  cause  is  of  by  no  means  infrequent  occurrence  after  severe 
surgical  operations,  especially  such  as  have  been  attended  with  much 
hemorrhage,  or  when  the  patient  is  in  a  weak  and  an£emic  condition. 


PUERPERAL    VENOUS    THROMBOSIS    AND    EMBOLISM.  Glo 

This  has  been  specially  dwelt  upon  as  a  not  infrequent  source  of 
death  after  operation  by  Fayrer  and  other  surgeons.^ 

Conditions  ivldcli  favor  Coagulation  in  tlie  Puerperal  tState. — But 
little  consideration  is  required  to  show  why  thrombosis  plays  so  im- 
portant a  part  in  the  puerperal  state,  for  there  most  of  the  causes 
favoring  its  occurrence  are  present.  Probably  there  is  no  other  con- 
dition in  which  they  exist  in  sa  marked  a  degree,  or  are  so  frequently 
combined.  The  blood  contains  an  excess  of  librine,  which  largely 
increases  in  the  latter  months  of  utero-gestation,  iintil,  as  has  been 
pointed  out  by  Andral  and  Gavarret,  it  not  unfrequently  contains  a 
third  more  than  the  average  amount  present  in  the  non-pregnant 
state.  As  soon  as  delivery  is  completed,  other  causes  of  blood  dys- 
crasia  come  into  operation.  Involution  of  the  largely  hypertrophied 
uterus  commences,  and  the  blood  is  charged  with  a  quantity  of  efiete 
material,  which  must  be  present,  in  greater  or  less  amount,  until 
that  process  is  completed.  It  is  an  old  observation  that  phlegmasia 
dolens  is  of  very  common  occurrence  in  patients  who  have  lost  much 
blood  during  labor;  thus  Dr.  Leishman  says:  "In  no  class  of  cases 
has  it  been  so  frequently  observed  as  in  women  whose  strength  has 
been  reduced  to  a  low  ebb  by  hemorrhage  either  during  or  after 
labor;  and  this,  no  doubt,  accounts  for  the  observation  made  by 
Merriman,  that  it  is  relatively  a  common  occurrence  after  placenta 
prsevia."^  An  examination  of  the  cases  in  which  death  results  from 
pulmonary  thrombosis  shows  the  same  ftxcts,  as  in  a  large  proportion 
of  them  severe  post-partura  hemorrhage  has  occurred.  The  exhaus- 
tion following  the  excessive  losses  so  common  after  labor  must  of 
itself  strongly  predispose  to  thrombosis,  and,  indeed,  loss  of  blood 
has  been  distinctly  pointed  out  by  Richardson  to  be  one  of  its  most 
common  antecedents.  "There  is,"  he  observes,  "a  condition  which 
has  been  long  known  to  favor  coagulation  and  fibrinous  deposition. 
I  mean  loss  of  blood,  and  syncope  or  exhaustion  during  impoverished 
states  of  the  body." 

Since  then  so  many  of  the  predisposing  causes  of  thrombosis  are 
present  in  the  puerperal  state,  it  is  hardly  a  matter  of  astonishment 
that  it  should  be  of  frequent  occurrence,  or  that  it  should  lead  to 
conditions  of  serious  gravity.  And  yet  the  attention  of  the  profession 
has  been  for  the  most  part  limited  to  a  study  of  one  only  of  the 
results  of  this  tendency  to  blood-clotting  after  delivery,  no  doubt 
because  of  its  comparative  frequency  and  evident  symptoms.  True 
the  balance  of  professional  opinion  has  lately  held  that  phlegmasia 
dolens  is  chiefly  the  result  of  some  morbid  condition  of  the  blood 
producing  plugging  of  the  veins  ;  but  the  wider  view  which  I  am 
attempting  to  maintain,  which  would  bring  this  disease  into  close 
relation  with  the  more  rarely  observed,  but  infinitely  important, 
obstructions  of  the  pulmonary  arteries,  has  scarcely,  if  at  all,  been 
insisted  on.  Doubtless  further  ii;ivestigation  will  show  that  it  is  not 
in  these  parts  of  the  venous  system  alone  that  puerperal  thrombosis 

I  Edin.  Mi-fl.  .Journ.,  March,  1861  ;  Indian  Annals  of  Med.,  July,  1867. 
^  Leishman,  System  of  Obstetrics,  p.  710. 


616  THE    PUERPERAL    STATE. 

occurs ;  but  the  symptoms  and  effects  of  venous  obstruction  else- 
where, important  though  they  may  be,  are  unknown. 

1  propose  then  to  describe  the  symptoms  and  pathology  of  blood- 
clot  in  the  right  side  of  the  heart  and  pulmonary  artery.  It  maybe 
useful  here  to  repeat  that  this  is  essentially  distinct  from  embolism 
of  the  same  parts.  The  latter  is  obstruction  due  to  the  impaction  of 
a  separated  portion  of  a  thrombus  formed  elsewhere,  and  for  its  pro- 
duction it  is  essential  that  thrombosis  should  have  preceded  it.  Em- 
bolism is  in  fact  an  accident  of  thrombosis,  not  a  primary  affection. 
The  condition  we  are  now  discussing  I  hold  to  be  primary,  precisely 
similar  in  its  causation  to  the  venous  obstruction  which,  in  other 
situations,  gives  rise  to  phlegmasia  dolens. 

At  the  threshold  of  this  inquiry  we  have  to  meet  the  objection, 
started  by  several  who  have  written  on  this  subject,^  that  sponta- 
neous coagulation  of  the  blood,  in  the  right  side  of  the  heart  and 
pulmonary  arteries,  is  a  mechanical  and  physiological  impossibility. 
This  was  the  view  of  Yirchow,  who,  with  his  followers,  maintained 
that  whenever  death  from  pulmonary  obstruction  occurred,  an  em- 
bolus was  of  necessity  the  starting-point  of  the  malady,  and  the 
nucleus  round  wdiich  secondary  deposition  of  fibrine  took  place. 
Virchow  holds  that  the  primary  factor  in  thrombosis  is  a  stagnant 
state  of  the  blood,  and  that  the  impulse  imparted  to  the  blood  by  the 
right  ventricle  is  of  itself  sufficient  to  prevent  coagulation.  It  is  to 
be  observed  that  these  objections  are  purely  theoretical.  Without 
denying  that  there  is  considerable  force  in  the  arguments  adduced,  I 
think  that  the  clinical  history  of  these  cases  strongly  favors  the  view 
of  spontaneous  coagulation ;  and  I  would  apply  to  the  theoretical 
objections  advanced  the  argument  used  by  one  of  their  strongest 
upholders,  with  regard  to  another  disputed  point,  "  Je  pref^re  laisser 
la  parole  aux  faits,  car  devant  eux  la  thdorie  s'incline.''^ 

The  anatomical  arrangement  of  the  pulmonary  arteries  shovs  how 
spontaneous  coagulation  may  be  favored  in  them;  for,  as  Dr.  Hum- 
phrey has  pointed  out,^  "  the  artery  breaks  up  at  once  into  a  number 
of  branches,  which  radiate  from  it,  at  different  angles,  to  the  several 
parts  of  the  lungs.  Consequently,  a  large  extent  of  surface  is  pre- 
sented to  the  blood,  and  there  are  numerous  angular  projections  into 
the  currents ;  both  which  conditions  are  calculated  to  induce  the 
spontaneous  coagulation  of  the  fibrine."  We  know  also,  that  throm- 
bosis generally  occurs  in  patients  of  feeble  constitution,  often  debili- 
tated by  hemorrhage,  in  whom  the  action  of  the  heart  is  much  weak- 
ened. These  facts,  of  themselves,  go  far  to  meet  the  objections  of 
those  who  deny  the  possibility  of  spontaneous  coagulation  at  the  roots 
of  the  pulmonary  arteries. 

Results  of  Post-mortem  Examinations. — The  records  of  post-mortem 
examinations  show  also,  that  in  many  of  the  cases  the  right  side  of 
the  heart,  as  well  as  the  larger  branches  of  the  pulmonary  arteries, 

'  See  especially  Berth.,  Des  Embolies,  p.  46  et  seq. 

2  Rertin,  Des  Embolies,  p.  149. 

3  Humphrey,  On  the  Coagulation  of  the  Blood  in  the  Venous  System  during  Life. 


PUERPERAL    VENOUS    THROMBOSIS    AND    ExMBOLISM.  617 

contained  firm,  leathery,  decolorized,  and  laminated  coagula,  which 
could  not  have  been  recently  formed.  The  advocates  of  the  purely 
embolic  theory  maintain  that  these  are  secondary  coagula,  formed 
around  an  embolus.  But  surely  the  mechanical  causes  which  are 
sufficient  to  prevent  spontaneous  deposition  of  fibrine,  would  also 
suffice  to  prevent  its  gathering  round  an  embolus ;  unless,  indeed,  the 
obstruction  was  sufficient  to  arrest  the  circulation  altogether,  when 
death  would  occur  before  there  was  any  time  for  secondary  deposit. 
Before  we  can  admit  the  possibility  of  embolism,  we  must  have  at 
least  one  factor,  that  is,  thrombosis  in  a  peripheral  vessel,  from  which 
an  embolus  can  come.  In  many  of  the  recorded  cases  nothing  of 
the  kind  was  found,  and  although,  as  is  argued,  this  may  have  been 
overlooked,  yet  such  an  oversight  can  hardly  always  have  been 
made. 

The  strongest  argument,  however,  in  favor  of  the  spontaneous 
origin  of  pulmonary  thrombosis  is  one  which  I  originally  pointed 
out  in  a  series  of  papers  ''  On  thrombosis  and  embolism  of  the  pul- 
monary artery  as  a  cause  of  death  in  the  puerperal  state. "^  I  there 
showed,  from  a  careful  analysis  of  25  cases  of  sudden  death  after 
delivery  in  which  accurate  post-mortem  examination  had  been  made, 
that  cases  of  spontaneous  thrombosis  and  embolism  may  be  divided 
from  each  other  by  a  clear  line  of  demarcation,  depending  on  the 
period  after  delivery  at  which  the  fatal  result  occurs.  In  7  out  of 
these  cases  there  was  distinct  evidence  of  embolism,  and  in  them 
death  occurred  at  a  remote  period  after  delivery ;  in  none  before  the 
nineteenth  day.  This  contrasts  remarkably  with  the  cases  in  which 
the  post-mortem  examination  afforded  no  evidence  of  embolism. 
These  amounted  to  15  out  of  the  25,  and  in  all  of  them,  with  one 
exception,  death  occurred  before  the  fourteenth  day,  often  on  the 
second  or  third.  The  reason  of  this  seems  to  be  that  in  the  former, 
time  is  required  to  admit  of  degenerative  changes  taking  place  in  the 
deposited  fibrine  leading  to  separation  of  an  embolus ;  while  in  the 
latter,  the  thrombosis  corresponds  in  time,  and  to  a  great  extent  no 
doubt  also  in  cause,  to  the  original  peripheral  thrombosis  from  which, 
in  the  former,  the  embolus  Avas  derived.  Many  cases  I  have  since 
collected  illustrate  the  same  rule  in  a  very  curious  and  instructive 
way. 

Another  clinical  fact  I  have  observed  points  to  the  same  conclusion. 
In  one  or  two  cases  distinct  signs  of  pulmonary  obstruction  have 
shown  themselves  without  proving  immediately  fatal,  and  shortly 
afterwards,  peripheral  thrombosis,  as  evidenced  by  phlegmasia  doleiis 
of  one  extremity,  has  commenced.  Here  the  peripheral  thrombosis 
obviously  followed  the  central,  both  being  produced  by  identical 
causes,  and  the  order  of  events,  necessary  to  uphold  the  purely  em- 
bolic theory,  was  reversed. 

I  hold,  then,  that  those  who  deny  the  possibility  of  spontaneous 
coagulation  in  the  heart  and  pulmonary  arteries  do  so  on  insufficient 
ground,  and  tliat  we  may  consider  it  to  be  an  occurrence,  rare  no 

'  Lancet,  1867. 
40 


618  THE    PUERPERAL    STATE. 

doubt,  but  still  sufficiently  often  met  with,  and  certainly  of  sufficient 
importance,  to  merit  very  careful  study. 

History. — Dr.  Chas.  D.  Meigs,  of  Philadelphia,  was  one  of  the  first  to 
direct  attention  to  spontaneous  coagulation  of  the  blood  in  the  right 
side  of  the  heart  and  pulmonary  arteries,  as  a  cause  of  sudden  death 
in  the  puerperal  state.  The  occurrence  itself,  however,  has  been 
carefully  studied  by  Paget,  whose  paper  was  published  in  1855,  four 
years  before  Meigs  wrote  on  the  subject.'  It  is  true  that  none  of 
"Paget's  cases  happened  after  delivery,  but  he  none  the  less  clearly 
apprehended  the  nature  of  the  obstruction.  In  1855,  Hecker^  at- 
tributed the  majority  of  these  cases  to  embolism  proper;  and  since 
that  date  most  authors  have  taken  the  same  view,  believing  that 
spontaneous  coagulation  only  occurs  in  exceptional  cases,  such  as 
those  in  which,  on  account  of  some  obstruction  in  the  lung  or  in  the 
debility  of  the  last  few  hours  before  death,  coagula  form  in  the 
smaller  ramifications  of  the  pulmonary  arteries,  and  gradually  creep 
backwards  towards  the  heart. 

Symptoms  of  Pulmonary  Obstruction. — The  symptoms  can  hardly 
bs  mistaken,  and  there  seems  to  be  no  essential  difference  between 
the  symptomatology  of  spontaneous  and  embolic  obstructions,  so  that 
the  same  description  will  suffice  for  both.  In  a  large  proportion  of 
cases  the  attack  comes  on  with  an  appalling  suddenness  which  forms 
one  of  its  most  striking  characteristics.  Nothing  in  the  condition  of 
the  patient  need  have  given  rise  to  the  least  suspicion  of  impending 
mischief,  when,  all  at  once,  an  intense  and  horrible  dyspnoea  comes 
on;  she  gasps  and  struggles  for  breath;  tears  off  the  coverings  from 
her  chest  in  a  vain  endeavor  to  get  more  air;  and,  often,  dies  in  a 
few  minutes,  long  before  medical  aid  can  be  had,  with  all  the  symp- 
toms of  asphyxia.  The  muscles  of  the  face  and  thorax  are  violently 
agitated  in  the  attempt  to  oxygenate  the  blood,  and  an  appearance 
closely  resembling  an  epileptic  convulsion  may  be  presented.  The 
face  may  be  either  pale  or  deeply  cyanosed.  Thus  in  one  case  I  have 
elsewhere  recorded,  which  was  an  undoubted  example  of  true  em- 
bolism, Mr.  Pedler,  the  resident  accoucheur  at  King's  College  Hos- 
pital, who  was  present  during  the  attack,  writes  of  the  patient,^ 
"  She  was  suffering  from  extreme  dyspnoea,  the  countenance  was 
excessively  pale,  her  lips  white,  the  face  generally  expressing  deep 
anxiety."  In  another,  which  was  probably  an  example  of  sponta- 
neous thrombosis,*  occurring  on  the  twelfth  day  after  delivery,  it  is 
stated  "  the  face  had  assumed  a  livid  purple  hue,  which  was  so  re- 
markable as  to  attract  the  attention  both  of  the  nurse  and  of  her 
mother,  who  was  with  her."  The  extreme  embarrassment  of  the  cir- 
culation is  shown  by  the  tumultuous  and  irregular  action  of  the  heart, 
in  its  endeavor  to  send  the  venous  blood  through  the  obstructed 
arteries.  Soon  it  gets  exhausted,  as  shown  by  its  feeble  and  flutter- 
ing beat.     The  pulse  is  thread-like,  and  nearly  imperceptible,  the 

1  Medico-Chir.  Trans.,  vol.  xxvii.  p.  162,  and  vol.  xxviii.  p.  352 ;  Philadelphia 
Medical  Examiner,  1849. 

2  Deutsche  Klinicke,  1855. 

3  Brit.  Med.  Journ.,  March  27,  1869.  *  Obst.  Trans.,  vol.  xii.  p.  194. 


PUERPERAL    VENOUS    THROMBOSIS    AND    EMBOLISM.  619 

respirations  short  and  hurried,  but  air  may  be  heard  entering  the 
lungs  freely.  The  intelligenee  during  the  struggle  is  unimpaired  ; 
and  the  dreadful  consoiousness  of  impending  death  adds  not  a  little 
to  the  patient's  sufferings,  and  to  the  terror  of  the  scene.  tSueli  is  an 
imperfect  account  of  the  symptoms,  gathered  from  a  record  of  what 
has  been  observed  in  fatal  cases.  It  Avill  be  readily  understood  why, 
in  the  presence  of  so  sudden  and  awful  an  attack,  symptoms  have  not 
been  recorded  with  the  accuracy  of  ordinary  clinical  observation. 

A  question  of  great  practical  interest,  which  has  been  entirely 
overlooked  by  writers  on  the  subject  is — Have  we  any  ground  for 
supposing  that  there  is  a  possibility  of  recovery  after  symptoms  of 
pulmonary  obstruction  have  developed  themselves?  That  such  a 
result  must  be  of  extreme  rarity  is  beyond  question ;  but  I  have 
little  doubt  that  in  some  few  cases,  entirely  inexplicable  on  any  other 
hypothesis,  life  is  prolonged  until  the  coagulum  is  absorbed,  and  the 
pulmonary  circulation  restored.  In  order  to  admit  of  this  it  is,  of 
course,  essential  that  the  obstruction  be  not  sufficient  to  prevent  the 
passage  of  a  certain  quantity  of  blood  to  the  lungs,  to  carry  on  the- 
vital  functions.  The  history  of  many  cases  tends  to  show  that  the 
obstructing  clot  was  present  for  a  considerable  time  before  death,  and 
that  it  was  only  when  some  sudden  exertion  was  made,  such  as  rising 
from  bed  or  the  like,  calling  for  an  increased  supply  of  blood  which 
could  not  pass  through  the  occluded  arteries,  that  fatal  symptoms 
manifested  themselves.  This  was  long  ago  pointed  out  by  Paget,^ 
who  says,  "  The  case  proves  that,  in  certain  circumstances,  a  great 
part  of  the  pulmonary  circulation  may  be  arrested  in  the  course  of  a 
week  (or  a  few  days  more  or  less),  Avithout  immediate  danger  to  life, 
or  any  indication  of  what  had  happened."  And,  after  referring  to 
some  illustrative  cases,  "Yet  in  all  these  cases  the  characters  of  the 
clots  by  which  the  pulmonary  arteries  were  obstructed,  showed 
plainly  that  they  had  been  a  week  or  more  in  the  process  of  forma- 
tion." If  we  admit  the  possibility  of  the  continuance  of  life  for  a 
certain  time,  we  must,  I  think,  also  admit  the  possibility,  in  a  few 
rare  cases,  of  eventual  complete  recovery.  What  is  required  is  time 
for  the  absorption  of  the  clot.  In  the  peripheral  venous  system 
coagula  are  constantly  removed  by  absorption.  So  strong,  indeed, 
is  the  tendency  to  this,  that  Humphrey  observes  with  regard  to  it, 
"It  appears  that  the  blood  is  almost  sure  to  revert  to  its  natural 
channel  in  process  of  time.''^  If  then  the  obstruction  be  only  par- 
tial, if  sufficient  blood  pass  to  keep  the  patient  alive,  and  a  sudden 
supply  of  oxygenated  blood  is  not  demanded  by  any  exertion  which' 
the  embarrassed  circulation  is  unable  to  meet,  it  is  not  inconceivable 
that  the  patient  may  live  until  the  obstruction  is  removed. 

Illustrative  Gases. — Such,  I  believe,  to  be  the  only  explanation  of 
certain  cases,  some  of  which,  on  any  other  hypothesis,  it  is  impossible 
to  understand.  The  symptoms  are  precisely  those  of  pulmonary 
obstruction,  and  the  description  I  have  given  above  may  be  applied 
to  them  in  every  particular ;  and,  after  repeated  paroxysms,  each  of 

>  Op.  cit.,  p.  358.  2  Med.  Chir.  Trans.,  voL  xxvii.  p.  14. 


620  THE    PUERPERAL    STATE. 

which  seems  to  threaten  immediate  dissolution,  an  eventual  recovery 
takes  place.  What,  then,  I  am  entitled  to  ask,  can  the  condition  be, 
if  not  that  which  I  suggest?  As  the  question  I  am  considering  has 
never,  so  far  as  I  am  aware,  been  treated  of  by  any  other  writer,  I 
may  be  permitted  to  state,  very  briefly,  the  facts  of  one  or  two  of 
the  cases  on  which  I  found  my  argument,  some  of  which  I  have 
already  published  in  detail  elsewhere. 

K.  H.,  delicate  young  lady.  Labor  easy.  First  child.  Profuse  post-partum 
liemorrhage.  Did  well  until  the  7th  day,  during  the  whole  of  which  she  felt  weak. 
Same  day  an  alarming  attack  of  dyspnoea  came  on.  For  several  days  she  remained 
in  a  very  critical  condition,  the  slightest  exertion  bringing  on  the  attacks.  A  slight 
blowing  murmur  heard  for  a  few  days  at  the  base  of  the  heart,  and  then  disappeared. 
For  two  months  patient  remained  in  the  same  state.  As  long  as  she  was  in  the 
recumbent  position  she  felt  pretty  comfortable ;  but  any  attempt  at  sitting  up  in  bed, 
or  any  unusual  exertion,  immediately  brought  on  the  embarrassed  respiration.  During 
all  this  time  it  was  found  necessary  to  administer  stimulants  profusely  to  ward  off  the 
attacks.     Eventually  the  patient  recovered  completely. 

Q.  F.,  set.  44.  Mother  of  twelve  children.  Confined  on  July  6.  On  the  11th  day 
she  went  to  bed  feeling  well.  There  was  no  swelling  or  discomfort  of  any  kind  about 
the  lower  extremities  at  this  time.  About  half-past  3  A.M.  she  was  sitting  up  in 
bed,  when  she  was  suddenly  attacked  with  an  indescribable  sense  of  oppression  in 
the  chest,  and  fell  back  in  a  semi-unconscious  state,  gasping  for  breath.  She  re- 
mained in  a  very  critical  condition,  with  the  same  symptoms  of  embarrassed  respira- 
tion, for  three  days,  when  they  gradually  passed  away.  Two  days  after  the  attack, 
phlegmasia  dolens  came  on,  the  leg  swelled,  and  remained  so  for  several  months. 

This  case  is  an  example  of  the  fact  I  have  already  referred  to,  of 
phlegmasia  dolens  coming  on  after  the  symptoms  of  pulmonary 
obstruction  had  manifested  themselves ;  the  inference  being  that 
both  depended  on  similar  causes  operating  on  two  distinct  parts  of 
the  circulatory  system. 

C.  H.,  fBt.  24.  Confined  of  her  first  child  on  August  20,  1867.  Thirty  hours  after 
delivery  she  complained  of  great  weakness  and  dyspnoea.  This  was  alleviated  by 
the  treatment  employed,  but  on  the  ninth  day,  after  making  a  sudden  exertion,  the 
dyspnoea  returned  with  increased  violence,  and  continued  unabated  until  I  saw  the 
patient  on  September  4,  fourteen  days  after  her  confinement.  The  following  are  the 
notes  of  her  condition  made  at  the  time  of  the  visit :  "I  found  her  sitting  on  the  sofa, 
propped  up  with  pillows,  as  she  said  she  could  not  breath  in  the  recumbent  position. 
The  least  excitement  or  talking  brought  on  the  most  aggravated  dyspnoea,  wliich  was 
so  bad  as  to  threaten  almost  instant  death.  Her  sufferings  during  these  paroxysms 
were  terrible  to  witness.  She  panted  and  struggled  for  breath,  and  her  chest  heaved 
with  short  gasping  respirations.  She  could  not  even  bear  any  one  to  stand  in  front 
of  her,  waving  them  away  with  her  hand,  and  calling  for  more  air.  These  attacks 
were  very  frequent,  and  were  brought  on  by  the  most  trivial  causes.  She  talked  in 
a  low  suppressed  voice,  as  if  she  could  not  spare  breath  for  articulation.  On  auscul- 
tation air  was  found  to  enter  the  lungs  freely  in  every  direction,  both  in  front  and 
behind.  Immediately  over  the  site  of  the  pulmonary  arteries  there  was  a  distinct 
harsh,  rasping  murmur,  confined  to  a  very  limited  space,  and  not  propagated  either 
upwards  or  downAvards.  The  heart-sounds  were  feeble  and  tumultuoiis."  These 
symptoms  led  me  to  diagnose  pulmonary  obstruction,  and  I,  of  course,  gave  a  most 
unfavorable  prognosis,  but  to  my  great  surprise  the  patient  slowly  recovered.  I  saw 
her  again  six  weeks  later,  wlien  her  heart-sounds  were  regular  and  distinct,  and  the 
murmur  had  completely  disappeared. 

E.  E.,  fet.  42,  was  confined  for  the  first  time  on  November  5,  1873,  in  the  sixth 
month  of  utero-gestation.  She  had  severe  post-partum  hemorrhage,  depending  on 
partially  adherent  placenta,  which  was  removed  artificially.  She  did  perfectly  well 
until  the  14th  day  after  delivei-y,  when  she  was  suddenly  attacked  with  intense 
dyspnoea,  aggravated  in  paroxysms.  Pulse  pretty  full,  130,  but  distinctly  inter- 
mittent. Air  entered  lungs  freely.  The  heart's  action  was  fluttering  and  irregular, 
and,  at  the  juncture  of  the  fourth  and  fifth  ribs  with  the  sternum,  there  was  a  loud 


PUERPERAL    VENOUS    THROMBOSIS    AND    EMBOLISM.  621 

blowing  systolic  murmur.  This  was  certainly  non-exist(3nt  before,  as  tlie  heart  had 
been  carefully  auscultated  before  administering  chloroform  during  labor.  For  two 
days  tlie  patient  reuiained  in  the  same  state,  her  death  being  almost  momentarily 
expected.  On  the  21st,  that  is  two  days  after  the  axjpearance  of  the  chest  symptoms, 
phlegmasia  dolens  of  a  severe  kind  developed  itself  in  the  right  thigh  and  leg.  She 
continued  in  the  same  state  for  many  days,  lying  more  or  less  tranquilly,  but  having 
paroxysms  of  the  most  intense  apnoea,  varying  from  two  to  six  or  eight  in  the  twenty- 
four  hours.  No  one  who  saw  her  in  one  of  these  could  have  expected  her  to  live 
throuo-h  it.  Shortly  after  the  first  appearance  of  the  jjaroxysms  it  was  observed  that 
the  cellular  tissue  of  the  neck  and  part  of  the  face  became  swollen  and  oedematous, 
giving  an  appearance  not  unlike  that  of  phlegmasia  dolens.  The  attacks  were  always 
relieved  by  stimulants.  These  she  incessantly  called  for,  declaring  that  she  felt  they 
kept  her  alive.  During  all  this  time  the  mind  was  clear  and  collected.  The  pulse 
varied  from  110  to  130.  Respirations  about  GO,  temperature  lOlo  to  102.5°.  By 
slow  degrees  the  patient  seemed  to  be  rallying.  The  paroxysms  diminished  in  num- 
ber, and  after  December  1  she  never  had  another,  and  the  breathing  became  free 
and  easy.  The  pulse  fell  to  80,  and  the  cardiac  murmur  entirely  disappeared.  The 
patient  remained,  however,  very  weak  and  feeble,  and  the  debility  seemed  to  increase. 
Towards  the  second  week  in  December  she  became  delirious,  and  died,  apparently 
exhausted,  without  any  fresh  chest  symptoms,  on  the  19th  of  that  month.  No  post- 
mortem examination  was  allowed. 

I  have  narrated  this  case,  although  it  terminated  fatally,  because 
I  hold  it  to  be  one  of  the  class  I  am  considering.  The  death  was 
certainly  not  due  to  the  obstruction,  all  symptoms  of  which  had 
disappeared,  but  apparently  to  exhaustion  from  the  severity  of  the 
former  illness.  It  illustrates  too  the  simultaneous  appearance  of 
symptoms  of  pulmonary  obstruction  and  peripheral  thrombosis. 
The  swelling  of  the  neck  was  a  curious  symptom,  which  has  not 
been  recorded  in  any  other  cases,  and  may  possibly  be  a  farther  proof 
of  the  analogy  between  this  condition  and  phlegmasia  dolens. 

Now,  it  may,  of  course,  be  argued  that  these  cases  do  not  prove 
ray  thesis,  inasmuch  as  I  only  assume  the  presence  of  a  coagulum. 
But  I  may  fairly  ask  in  return  what  other  condition  could  possiblv 
explain  the  symptoms  ?  They  are  precisely  those  which  are  noticed 
in  death  from  undoubted  pulmonary  obstruction.  No  one  seeing 
one  of  them,  or  even  reading  an  account  of  the  symptoms,  while 
ignorant  of  the  result,  could  hesitate  a  single  instant  in  the  diagnosis. 
Surely,  then,  the  inference  is  fair  that  they  depended  on  the  same 
cause  ?  In  the  very  nature  of  things  my  hypothesis  cannot  be  veri- 
fied by  post-mortem  examination ;  but  there  is  at  least  one  case  on 
record,  in  which,  after  similar  symptoms,  a  clot  was  actually  found. 
The  case  is  related  by  Dr.  Eichardson^  It  was  that  of  a  man  who 
for  weeks  had  symptoms  precisely  similar  to  those  observed  in  the 
cases  I  have  narrated.  In  one  of  his  agonizing  struggles  for  breath 
he  died,  and  after  death  it  was  found  "that  a  fibrinous  band,  having 
its  hold  in  the  ventricle,  extended  into  the  pulmonary  artery."  This 
observation  proves  to  a  certainty  that  life  may  continue  for  weeks 
after  the  deposition  of  a  coagulum  ;  and,  moreover,  this  condition 
was  precisely  what  we  should  anticipate,  since,  of  course,  the  ob- 
structing coagulum  must  necessarily  be  small,  otherwise  the  vital 
functions  would  be  immediately  arrested. 

•  Clinical  Essays,  p.  224  et  seq. 


622  THE    PUERPERAL    STATE. 

Cardiac  Murm.urs  in  Pulmonary  Obstruction. — There  is  a  symptom 
noted  in  two  of  the  above  eases,  and  to  less  extent  in  a  third,  which 
has  not  been  mentioned  in  any  account  of  fatal  cases  occurring  after 
delivery,  viz.,  a  murmur  over  the  site  of  the  pulmonary  arteries. 
It  is  a  sign  we  should  naturally  expect,  and  very  possibly  it  would 
be  met  with  in  fatal  cases  if  attention  were  particularly  directed  to 
the  point.  In  both  these  instances  it  v/as  exceedingly  well  marked, 
and  in  both  it  entirely  disappeared  when  the  symptoms  abated.  The 
probability  of  such  a  murmur  being  audible  in  cases  of  thrombosis 
of  the  pulmonary  artery,  has  been  recognized  by  one  of  our  highest 
authorities  in  cardiac  disease,  who  actually  observed  it  in  a  non- 
puerperal case.  In  the  last  edition  of  his  work  on  diseases  of  the 
heart,  Dr.  Walshe^  says :  "  The  only  physical  condition  connected 
with  the  vessel  itself  would  probably  be  systolic  basic  murmur  fol- 
lowing the  course  of  the  pulmonary  main  trunk  and  of  its  immediate 
divisions  to  tlie  left  and  right  of  the  sternum.  This  sign  I  most 
certainly  heard  in  an  old  gentleman  whose  life  was  brought  to  a 
sudden  close,  in  the  course  of  an  acute  affection,  by  coagulation  in 
the  pulmonary  artery,  and  to  a  moderate  extent  in  the  right  ven- 
tricle." 

Similar  cases  have,  probably,  been  overlooked  or  misinterpreted. 
Many  seem  to  have  been  attributed  to  shock,  in  the  absence  of  a 
better  explanation,  a  condition  to  which  they  bear  no  kind  of  re- 
semblance. 

Causes  of  Death. — The  precise  mode  of  death  in  pulmonary  ob- 
struction, whether  dependent  on  thrombosis  or  embolism,  has  given 
rise  to  considerable  difference  of  opinion.  Yirchow  attributes  it  to 
syncope,^  depending  on  stoppage  of  the  cardiac  contraction.  Panum,^ 
on  the  other  hand,  contests  this  view,  maintaining  that  the  heart  con- 
tinues to  beat  even  after  all  signs  of  life  have  ceased.  Certainly 
tumultuous  and  irregular  pulsations  of  the  heart  are  prominent 
symptoms  in  most  of  the  recorded  cases,  and  are  not  reconcilable 
with  the  idea  of  syncope.  Panum's  own  theory  is,  that  death  is  the 
result  of  cerebral  anaemia.  Paget  seems  to  think  that  the  mode  of 
death  is  altogether  peculiar,  in  some  respects  resembling  syncope,  in 
others  an^eniia.  Bertin,  who  has  discussed  the  subject  at  great 
length,  attributes  the  fatal  result  purely  to  asphyxia.  The  condition, 
indeed,  is  in  all  respects  similar  to  that  state  ;  the  oxygenation  of  the 
blood  being  prevented,  not  because  air  cannot  get  to  the  blood,  but 
because  blood  cannot  get  to  the  air.  The  symptoms  also  seem  best 
explained  by  this  theo'ry  ;  the  intense  dyspnoea,  the  terrible  struggle 
for  air,  the  preservation  of  intelligence,  the  tumultuous  action  of  the 
heart,  are  certainly  not  characteristic  either  of  syncope  or  anemia. 

Post-mortem  Appearances  of  Clots. — The  anatomical  character  of 
the  clots  seems  to  vary  considerably.  Ball,  by  whom  they  have  been 
most  carefully  described,  believes  \hat  they  generally  commence  in 
the    smaller   ramifications   of   the    arteries,    extending    backwards 

1  Walshe,  On  Diseases  of  the  Heart,  4th  ed.  1873. 

2  Gesamm.  Abhandl.,  1862,  p.  316.  ^  Virchow's  Archiv,  1863. 


PUERPERAL    VENOUS    THROMBOSIS    AND    EiMBOLISM.  623 

towards  the  heart,  and  filling  the  vessels  more  or  less  completely. 
Towards  its  cardiac  extremity  the  coagulum  terminates  iu  a  rounded 
head,  in  which  respect  it  resembles  those  spontaneously  formed  in 
the  peripheral  veins.  It  is  non-adherent  to  the  coats  of  the  vessels, 
and  the  blood  circulates,  when  it  can  do  so  at  all,  between  it  and  the 
vascular  walls.  Such  clots  are  white,  dense,  and  of  a  homogeneous 
structure,  consisting  of  layers  of  decolorized  iibrine,  firm  at  the  peri- 
phery, where  the  fibrine  has  been  most  recently  deposited,  and  soft- 
ened in  the  centre,  where  amylaceous  or  fatty  degeneration  has 
commenced.  Ball  maintains  that  if  the  coagulum  have  commenced 
in  the  larger  branches  of  the  arteries,  it  must  have  first  begun  in 
the  ventricle,  and  extended  into  them.  According  to  Humphrey, 
the  same  changes  take  place  in  pulmonary  as  in  peripheral  thrombi, 
and  they  may  become  adherent  to  the  walls  of  the  vessels,  or  con- 
verted into  threads  or  bands.  When  the  obstruction  is  due  to  em- 
bolism, provided  the  case  is  a  well-marked  one,  and  the  embolus  of 
some  size,  the  appearances  presented  are  different.  We  have  no 
longer  a  laminated  and  decolorized  coagulum,  with  a  rounded  head, 
similar  to  a  peripheral  thrombus.  The  obstruction  in  this  case 
generally  takes  place  at  the  point  of  bifurcation  of  the  artery,  and 
we  there  meet  with  a  grayish-white  mass,  contrasting  remarkably 
with  the  more  recently  deposited  fibrine  before  and  behind  it.  It  may 
be  that  the  form  of  the  embolus  shows  that  it  has  recently  been 
separated  from  a  clot  elsewhere ;  and  in  many  cases  it  has  been  pos- 
sible to  fit  the  travelled  portion  to  the  extremity  of  the  clot  from 
which  it  has  been  broken.  We  may  also,  perhaps,  find  that  the 
embolus  has  undergone  an  amount  of  retrograde  metamorphosis 
corresponding  with  that  of  the  peripheral  thrombus  from  which  we 
suppose  it  to  have  come,  but  differing  from  that  of  the  more  recently 
deposited  fibrine  around  it.  It  must  be  admitted,  however,  that  the 
anatomical  peculiarities  of  the  coagula  will  by  no  means  always 
enable  us  to  trace  them  to  their  true  origin.  In  many  cases  emboli 
may  escape  detection  from  their  smallness,  or  from  the  quantity  of 
fibrine  surrounding  them. 

Treatment. — But  few  words  need  be  said  as  to  the  treatment  of 
pulmonary  obstruction.  In  a  large  majority  of  cases  the  fatal  result 
so  rapidly  follows  the  appearance  of  the  symptoms,  that  no  time  is 
given  us  even  to  make  an  attempt  to  alleviate  the  patient's  suffer- 
ings. Should  we  meet  with  a  case  not  immediately  fatal,  it  seems 
that  there  are  but  two  indications  of  treatment  affording  the  slightest 
rational  ground  of  hope. 

1.  To  keep  the  patient  alive  by  the  administration  of  stimulants — 
brandy,  ether,  ammonia,  and  the  like — to  be  repeated  at  intervals 
corresponding  to  the  intensity  of  the  paroxysms,  and  the  results  pro- 
duced. In  the  cases  I  have  above  narrated,  in  which  recovery  ensued, 
this  took  the  place  of  all  other  medication.  Possibly  leeches,  or  dry 
cupping  to  the  chest,  might  prove  of  some  service  in  relieving  the 
circulation. 

2.  To  enjoin  the  most  absolute  and  complete  repose.  The  object 
of  this  is  evident.    The  only  chance  for  the  patient  seems  to  be,  that 


624  THE    PUERPERAL    STATE. 

the  vital  functions  should  be  carried  on  until  the  coagulum  has  been 
absorbed,  or,  at  least,  until  it  has  been  so  much  lessened  in  size  as  to 
admit  of  blood  passing  it  to  the  lungs.  The  slightest  movements 
may  give  rise  to  a  fatal  paroxysm  of  dyspnoea,  from  the  increased 
supply  of  oxygenated  blood  required.  It  must  not  be  forgotten  that 
in  a  large  proportion  of  cases  death  immediately  followed  some  exer- 
tion in  itself  trivial,  such  as  rising  out  of  bed.  Too  much  attention, 
then,  cannot  be  given  to  this  point.  The  patient  should  be  absolutely 
still ;  she  should  be  fed  with  abundance  of  fluid  food,  such  as  milk, 
strong  soups,  and  the  like ;  and  should  on  no  account  be  permitted 
to  raise  herself  in  bed,  or  attempt  the  slightest  muscular  exertion. 
If  we  are  fortunate  enough  to  meet  with  a  case  apparently  tending 
to  recovery,  these  precautions  must  be  carried  on  long  after  the 
severity  of  the  symptoms  has  lessened,  for  a  moment's  imprudence 
may  suffice  to  bring  them  back  in  all  their  original  intensity. 

Bertin,^  indeed,  recommends  a  system  of  treatment  very  different 
from  this.  In  the  vain  hope  that  the  violent  effort  induced  may 
cause  the  displacement  of  the  impacted  embolus  (to  which  alone  he 
attributes  pulmonary  obstruction),  he  recommends  the  administra- 
tion of  emetics.  Few,  I  fancy,  will  be  found  bold  enough  to  attempt 
so  hazardous  a  plan  of  treatment. 

Various  drugs  have  been  suggested  in  these  cases.  Ei chard  son 
recommended  ammonia,  a  deficiency  of  which  he  at  that  time  believed 
to  be  the  chief  cause  of  coagulation.  He  has  since  advised  that 
liquor  ammonige  should  be  given  in  large  doses,  20  minims  every 
hour,  in  the  hope  of  causing  solution  of  the  deposited  fibrine ;  and 
he  has  stated  that  he  has  seen  good  results  from  the  practice.  Others 
advise  the  administration  of  alkalies,  in  the  hope  that  they  may 
favor  absorption.  The  best  that  can  be  said  for  them  is,  that  they 
are  not  likely  to  do  much  harm. 


CHAPTEE   VII. 

PUEEPERAL  ARTERIAL  THROMBOSIS  AND  EMBOLISM. 

The  same  condition  of  the  blood  which  so  strongly  predisposes  to 
coagulation  in  the  vessels  through  which  venous  blood  circulates, 
tends  to  similar  results  in  the  arterial  system.  These,  however,  are 
by  no  means  so  common,  and  do  not,  as  a  rule,  lead  to  such  important 
consequences.  The  subject  has  been  but  little  studied,  and  almost 
all  our  knowledge  of  it  is  derived  from  a  very  interesting  essay  by 
Sir  James  Simpson.^     As  I  have  devoted  so  much  space  to  the  con- 

«  Op.  cit.  p.  393.  2  Selected  Obst.  Works,  vol.  i.  p.  523. 


PUERPERAL  ARTERIAL  THROMBOSIS  AND  EMBOLISM.   G25 

sideratioii  of  venous  thrombosis  and  embolism,  I  shall  but  briefly 
consider  the  effects  of  arterial  obstruction. 

Causes. — In  a  considerable  number  of  recorded  cases  the  obstruc- 
tion has  resulted  from  the  detachment  of  vegetations  deposited  on 
the  cardiac  valves,  the  result  of  endocarditis,  either  produced  by 
antecedent  rheumatism,  or  as  a  complication  of  the  puerperal  state. 
Sometimes  the  obstruction  seems  to  depend  on  some  general  blood 
dyscrasia,  similar  to  that  producing  venous  thrombosis,  or  on  some 
local  change  in  the  artery  itself.  Thus  Simpson  records  a  case  ap- 
parently produced  by  local  arteritis,  which  caused  acute  gangrene  of 
both  lower  extremities,  ending  fatally  in  the  third  week  after  de- 
livery. In  other  cases  it  has  been  attributed  to  coagulation  follow- 
ing spontaneous  laceration  and  corrugation  of  the  internal  coat  of  the 
artery. 

Synqjtoms. — The  symptoms  ot  puerperal  arterial  obstruction  must, 
of  course,  vary  with  the  particular  arteries  aft'ected.  Those,  with 
the  obstruction  of  which  we  are  most  familiar,  are  the  cerebral,  the 
humeral,  and  the  femoral.  The  effects  produced  must  also  be  modi- 
fied by  the  size  of  the  embolus,  and  the  more  or  less  complete  ob- 
struction it  produces.  Thus,  for  example,  if  the  middle  cerebral 
artery  be  blocked  up  entirely,  the  functions  of  those  portions  of  the 
brain  supplied  by  it  will  be  more  or  less  completely  arrested,  and 
hemiplegia  of  the  opposite  side  of  the  body,  followed  by  softening  of 
the  brain-texture,  will  probably  result.  If  the  nervous  symptoms 
be  developed  gradually,  or  increase  in  intensity  after  their  first  ap- 
pearance, it  may  be  that  an  obstruction,  at  first  incomplete,  has  in- 
creased by  the  de[)Osition  of  fibrine  around  it.  So  the  occasional 
sudden  supervention  of  blindness,  with  destruction  of  the  eyeball — 
cases  of  which  are  recorded  by  Simpson — not  improbably  depend  on 
occlusion  of  the  ophthalmic  artery,  the  function  of  the  organ  de- 
pending on  its  supply  through  the  single  artery.  The  effects  of  ob- 
struction of  the  visceral  arteries  in  the  puerperal  state  are  entirely 
unknown  ;  but  it  is  far  from  unlikely  that  further  investigation  may 
prove  them  to  be  of  great  importance.  In  the  extremities  arterial 
obstruction  produces  effects  which  are  well  marked.  They  are  classi- 
fied by  Simpson  under  the  following  heads  :  1.  Arrest  of  pulse  heJoio 
the  site  of  ohstruction. — This  has  been  observed  to  come  on  either 
suddenly  or  gradually,  and  if  the  occlusion  be  in  one  of  the  large 
arterial  trunks,  it  is  a  symptom  which  a  carefal  examination  will 
readily  enable  us  to  detect.  2.  Increased  force  of  pulsation  in  the  ar- 
teries above  the  seat  of  ohstruction.  3,  Fall  in  the  temperature  of  the 
limh. — This  is  a  symptom  which  is  easily  appreciable  by  the  ther- 
mometer, and,  when  the  main  artery  of  the  limb  is  occluded,  the 
coldness  of  the  extremity  is  well  marked.  4.  Lesions  of  motor  and 
sensory  functions .^  paralysis,  neuralgia,  etc.  etc. — Loss  of  power  in  the 
affected  limb  is  often  a  prominent  symptom,  and  when  it  comes  on 
suddenly,  and  is  complete,  the  main  artery  will  probably  be  occluded. 
It  may  be  diagnosed  from  paralysis  depending  on  cerebral  or  spinal 
causes  by  the  absence  of  head  symptoms,  by  the  history  of  the  attack, 
and  by  the  presence  of  other  indications  of  arterial  obstruction,  such 


626  THE    PUERPERAL    STATE. 

as  loss  of  pulsation  in  the  artery,  fall  of  temperature,  etc.  The  sen- 
sory functions  in  these  cases  are  generally  also  seriously  disturbed, 
not  so  much  by  loss  of  sensation,  as  by  severe  pain  and  neuralgia. 
Sometimes  the  pain  has  been  excessive,  and  occasionally  it  has  been 
the  first  symptom  which  directed  attention  to  the  state  of  the  limb. 
5.  Oanyrene  heloiv  or  heyond  the  seat  of  arterial  obstruction. — Several 
interesting  cases  are  recorded,  in  which  gangrene  has  followed  arte- 
rial obstruction.  Generally  speaking  gangrene  will  not  follow 
occlusion  of  the  main  arterial  trunk  of  an  extremity,  as  the  collateral 
circulation  becomes  soon  sufficiently  developed  to  maintain  its  vitality. 
In  many  of  the  cases  either  thrombi  have  obstructed  the  channels  of 
collateral  circulation  as  v,^ell,  or  the  veins  of  the  limb  have  also 
been  blocked  up.  When  such  extensive  obstructions  occur  they 
obviously  cannot  be  embolic,  but  must  depend  on  a  local  thrombosis, 
traceable  to  some  general  blood  dyscrasia  depending  on  the  puerperal 
state. 

Treatment. — Little  can  be  said  as  to  the  treatment  of  such  cases, 
which  must  vary  with  the  gravity  and  nature  of  the  symptoms  in 
each.  Beyond  absolute  rest  (in  the  hope  of  eventual  absorption  of 
the  thrombus  or  embolus),  generous  diet,  attention  to  the  general 
health  of  the  patient,  and  sedative  applications  to  relieve  the  local 
pain,  there  is  little  in  our  power.  Should  gangrene  of  an  extremity 
supervene  in  a  puerperal  patient,  the  case  must  necessarily  be  well- 
nigh  hopeless.  Simpson,  however,  records  one  instance  in  which 
amputation  was  performed  above  the  line  of  demarcation,  the  patient 
eventually  recovering. 


CHAPTER  VIIT. 


OTHER  CAUSES  OF  SUDDEN"  DEATH  DURING  LABOR  AND  THE 
PUERPERAL  STATE. 

A  LARGE  number  of  the  cases  in  which  sudden  death  occurs  during 
or  after  delivery  find  their  explanation,  as  I  have  already  pointed 
out,  in  thrombosis  or  embolism  of  the  heart  and  pulmonary  arteries. 
Probably,  many  cases  of  the  so-called  idiopathic  asphyxia  were  in 
fact  examples  of  this  accident,  the  true  nature  of  which  had  been 
misunderstood.  Besides  these  there  are,  no  doubt,  many  other  con- 
ditions which  may  lead  to  a  suddenly  fatal  result  in  connection  with 
parturition. 

Some  of  these  are  of  an  organic,  others  of  a  functional  nature. 

Organic  Causes. — Among  the  former  may  be  mentioned  cases  in 
which  the  straining  efforts  of  the  second  stage  of  labor  have  pro- 
duced death  in  patients  suffering  from  some  pre-existent  disease  of 


CAUSES  OF  SUDDEN  DEATH  DURING  LABOR.        62T 

the  heart.  Eui)ture  of  that  organ  has  probably  occurred  from  fatty 
degeneration  of  its  walls.  Dehous'  narrates  an  instance  in  which  the 
efforts  of  labor  caused  the  rupture  of  an  aneurism.  Another  case, 
from  interference  with  the  action  of  the  heart  in  a  patient  who  had 
pericardial  effusion,  is  narrated  by  Ramsbotham.  L)r.  Devilliers  re- 
lates an  instance  occurring  in  a  young  woman  during  the  second 
stage  of  labor.  The  heart  was  found  to  be  healthy,  but  the  lungs 
were  intensely  congested,  and  blood  was  extensively  extravasated 
all  through  their  texture.  This  was  probably  caused  by  pulmonary 
congestion  and  apoplexy,  produced  by  the  severe  straining  efforts. 
Many  cases  from  effusion  of  blood  into  the  brain -substance,  or  on  its 
surface,  are  on  record,  no  doubt  in  patients  who,  from  arterial  de- 
generation or  other  causes,  were  predisposed  to  apoplectic  effusions. 
The  so-called  apoplectic  convulsions,  formerly  described  in  most 
works  on  obstetrics  as  a  variety  of  puerperal  convulsions,  are  evi- 
dently nothing  more  than  apoplexy  coming  on  during  or  after  labor. 
As  regards  their  pathology  they  do  not  seem  to  differ  from  ordinary 
cases  of  apoplexy  in  the  non-pregnant  condition.  One  example  is 
recorded  of  death  which  was  attributed  to  rupture  of  the  diaphragm 
from  excessive  action  in  the  second  stage. 

Functional  Causes. — Among  the  causes  of  death  which  cannot  be 
traced  to  some  distinct  organic  lesion,  ma}'  be  classed  cases  of  syncope, 
shock,  and  exhaustion.  Many  instances  of  this  kind  are  recorded. 
Thus  in  some  women  of  susceptible  nervous  organization,  the  severity 
of  the  suffering  appears  to  bring  on  a  condition,  similar  to  that  pro- 
duced by  excessive  shock  or  exhaustion,  which  has  not  unfrequently 
proved  fatal.  Several  examples  of  this  kind  have  been  cited  by 
McClintock.2  It  is  also  not  unlikely  that  sudden  syncope  sometimes 
produces  a  fatal  result,  during  or  after  labor.  Most  cases  of  death, 
otherwise  inexplicable,  used  to  be  referred  to  this  cause ;  but  accu- 
rate autopsies  were  seldom  made,  and  even  when  they  were — the 
important  effects  of  pulmonary  coagula  being  unknown — it  is  more 
than  probable  that  the  true  cause  of  death  was  overlooked.  It  has 
been  supposed  that  the  sudden  removal  of  pressure  from  the  veins 
of  the  abdomen,  by  the  emptying  of  the  gravid  uterus  after  delivery, 
may  favor  an  increased  afflux  of  blood  into  the  lower  parts  of  the 
body,  and  thus  tend  to  an  anaemic  condition  of  the  brain,  and  the 
production  of  syncope.  However  this  may  be,  the  possibility  of  its 
occurrence,  and  its  manifest  danger  in  a  recently  delivered  woman, 
are  sufficient  reasons  for  enforcing  the  recumbent  position  after  labor 
is  over.  In  some  of  the  cases  tlie  syncope  was  evidently  produced 
by  the  patient's  suddenly  sitting  upright. 

Death  from  Air  in  the  Veins. — Some  cases  of  sndden  death  imme- 
diately after  labor  seem  to  be  due  to  the  entrance  of  air  into  the 
veins.  Six  examples  are  cited  by  McCliiitock  which  Avere  probably 
due  to  this  cause.  La  Chapelle  relates  two.  An  interesting  case  is 
related  by  M.  Lionet.^     In  this  the  patient  died  five  and  a  half  hours 

'  Dehous,  Sur  les  Morts  subites. 

2  Union  Medic,  1853.  8  Dehous,  op.  cit.  p.  58. 


628  THE    PUERPERAL    STATE, 

after  an  easy  and  natural  labor,  the  chief  symptoms  being  extreme 
pallor,  efforts  at  vomiting,  and  dyspnoea.  Air  was  found  in  the  heart 
and  in  the  arachnoid  veins.  There  can  be  no  question  that  the  ute- 
rine sinuses  after  delivery  are  nearly  as  well  adapted  as  the  veins  of 
the  neck  for  allowing  the  entrance  of  air.  They  are  firmly  attached 
to  the  muscular  walls  of  the  uterus,  so  that  they  gape  open  when 
that  organ  is  relaxed,  and  it  is  easy  to  understand  how  air  might 
enter.  Indeed,  in  the  post-mortem  examination  in  one  of  the  cases 
occurring  in  the  practice  of  Mme.  La  Chapelle,  it  is  started  that  "  the 
uterine  sinuses  opened  in  the  interior  of  the  uterus  by  large  orifices 
(one  line  and  a  half  in  diameter),  through  which  air  could  readily  be 
blown  as  far  as  the  ihac  veins,  and  vice  versa^  The  condition  of 
the  uterus  after  delivery  also  enables  the  air  to  have  ready  access  to 
the  mouths  of  the  sinuses,  for  the  alternate  relaxation  and  contrac- 
tion of  the  uterus,  occurring  after  the  placenta  is  expelled,  would 
tend  to  draw  in  the  air  as  by  a  suction  pump.  Hence,  an  additional 
reason  for  insisting  on  firm  contraction  of  the  uterus,  as  this  will 
lessen  the  risk  of  this  accident. 

Cause  of  Death  m  such  Cases. — The  precise  mechanism  of  death 
from  air  in  the  veins,  has  been  a  subject  of  dispute  among  patholo- 
gists. By  Bichat,^  it  was  referred  to  antemia  and  syncope  from  want 
of  blood  in  the  vessels  of  the  brain,  which  are  occupied  by  air; 
Nysten^  attributed  it  to  distension  of  the  cavities  of  the  heart  by 
rarefied  air,  producing  paralysis  of  its  wall ;  Leroy  to  a  stoppage  of 
the  pulmonary  circulation,  and  consequent  want  of  proper  blood- 
supply  to  the"^  left  heart ;  while  Leroy  d'Etoilles  thought  it  might 
depend  on  any  of  these  causes,  or  a  combination  of  all  of  them. 
These,  and  many  other  hypotheses  on  the  subject,  have  been  ad- 
vanced, to  all  of  which  serious  objection  could  be  raised.  The  most 
recent  theory  is  one  maintained  by  Yirchow  and  Oppolzer,^  and  more 
recently  by  Feltz,  which  attributes  the  fatal  results  to  impaction  of 
the  air-globules  in  the  lesser  divisions  of  the  jDulmonary  arteries, 
where  they  form  gaseous  emboli,  and  cause  death  exactly  in  the  same 
way  as  when  the  obstruction  depends  on  a  fibrinous  embolus.  The 
symptoms  observed  in  fatal  cases  closely  correspond  to  those  of  pul- 
nionary  obstruction,  and  it  is  not  unlikely  that  some  cases,  attributed 
to  other  causes,  may  really  depend  on  the  entrance  of  air  through 
the  uterine  sinuses.  Such,  for  example,  was  most  probably  the 
explanation  of  a  case  referred  to  by  Dr.  Graily  Hewitt  in  a  discussion 
at  the  Obstetrical  Society.*  Death  occurred  shortly  after  the  removal 
of  an  adherent  placenta,  during  which,  no  doubt,  air  could  readily  enter 
the  uterine  cavity.  The  symptoms,  viz.,  "  severe  pain  in  the  cardiac 
region,  distress  as  regards  respiration,  and  pulselessness,"  are  identical 
with  those  of  pulmonary  obstruction.  Dr.  Hewitt  refers  the  death 
to  shock,  Avhich  certainly  does  not  generally  produce  such  phenomena. 

'  Reclierches  snr  la  Vie  etla  Mort,  1853. 
2  Nysten,  Recherches  de  Phys.  et  Chem.  Path.,  1811. 

^  Casuistics  des  Embolie  ;    Wiener  Med.  Woch.,  1863.     Des  Embolics  Capillaires, 
1868.     Op.  cit.  p.  115. 

4  Obstet.  Trans.,  vol.  x.  p.  28, 


PERIPHERAL    VENOUS    TIlROiMBOSIS,    ETC.  629 


CHAPTEE  IX. 

PERIPHERAL     VENOUS     THROMBOSIS — (SYN.  :      CRURAL     PHLEBITIS — 

PHLEGMASIA      DOLENS — ANASARCA     SEROSA — (EDEMA     LACTEUM 

WHITE  LEG,  ETC.). 

We  now  come  to  discuss  the  symptoms  and  pathology  of  the  con- 
ditions associated  witli  the  formation  of  thrombi  in  the  peripheral 
venous  system,  or  rather  in  the  veins  of  the  lower  extremities,  since 
too  little  is  known  of  their  occurrence  in  other  parts  to  enable  us  to 
say  anything  on  the  subject. 

The  most  important  of  these  is  the  well-known  disease  which, 
under  the  name  of  phlegmasia  dolens,  has  attracted  much  attention, 
and  given  rise  to  numerous  theories  as  to  its  nature  and  pathology. 
In  describing  it  as  a  local  manifestation  of  a  general  blood-dyscrasia, 
and  not  as  an  essential  local  disease,  I  am  making  an  assumption  as 
to  its  pathology,  that  many  eminent  authorities  would  not  consider 
justifiable.  I  have,  however,  already  stated  some  of  the  reasons  for 
so  doing,  and  I  shall  shortly  hope  to  show  that  this  view  is  not  in- 
compatible with  the  most  probable  explanation  of  the  peculiar  state 
of  the  affected  limb. 

Symptoms. — The  first  symptom  which  usually  attracts  attention  is 
severe  pain  in  some  part  of  the  limb  that  is  about  to  be  affected. 
The  character  of  the  pain  varies  in  different  cases.  In  some  it  is 
extremely  acute,  and  is  most  felt  in  the  neighborhood  of  and  along 
the  course  of  the  chief  venous  trunks.  It  may  begin  in  the  groin  or 
hip,  and  extend  downwards ;  or  it  may  commence  in  the  calf  and 
proceed  upwards  towards  the  pelvis.  The  pain  abates  somewhat 
after  swelling  of  the  limb  (which  generally  begins  within  twenty- 
four  hours),  but  it  is  always  a  distressing  symptom,  and  continues  as 
long  as  the  acute  stage  of  the  disease  lasts.  The  restlessness,  want 
of  sleep,  and  suffering  which  it  produces  are  sometimes  excessive. 
Coincident  with  the  pain,  and  sometimes  preceding  it,  more  or  less 
malaise  is  experienced.  The  patient  may  for  a  day  or  two  be  rest- 
less, irritable,  and  out  of  sorts,  without  any  very  definite  cause:  or 
the  disease  may  be  ushered  in  by  a  distinct  rigor.  Generally  there 
is  constitutional  disturbance,  varying  with  the  intensity  of  the  case. 
The  pulse  is  rapid  and  weak,  120  or  thereabouts ;  the  temperature 
elevated  from  101°  to  102°,  with  an  evening  exacerbation.  The  pa- 
tient is  thirsty  ;  the  tongue  glazed,  or  white  and  loaded  ;  the  bowels 
constipated.  In  some  few  cases,  when  the  local  affection  is  slight, 
none  of  these  constitutional  sj^mptoms  are  observed. 

Condition  of  the  Affected  Linih. — The  characteristic  swelling  rapidly 
follows  the  commencement  of  the  symptoms.     It  generally  begins  in 


630  THE    PUERPERAL    STATE. 

the  groin,  from  whence  it  extends  downwards.  It  may  be  limited  to 
the  thigh ;  or  the  whole  limb,  even  to  the  feet,  may  be  implicated. 
More  rarely  it  commences  in  the  calf  of  the  leg,  extending  upwards 
to  the  thigh,  and  downwards  to  the  feet.  The  affected  parts  have  a 
peculiar  appearance,  which  is  pathognomonic  of  the  disease.  They 
are  hard,  tense,  and  brawny  ;  of  a  shiny,  white  color ;  and  not  yield- 
ing on  pressure,  except  towards  tlie  beginning  and  end  of  the  illness. 
Tlie  appearances  presented  are  quite  different  from  those  of  ordinary 
oedema.  When  the  whole  thigh  is  affected  the  limb  is  enormously 
increased  in  size.  Frequently  the  venous  trunks,  especially  the 
femoral  and  popliteal  veins,  are  felt  obstructed  with  coagula,  and 
rolling  under  the  finger.  They  are  painful  when  handled,  and  in 
their  course  more  or  less  redness  is  occasionall}^  observed.  Either 
leg  may  be  attacked,  but  the  left  more  frequently  than  the  right. 
There  is  a  marked  tendency  for  the  disease  to  spread,  and  we  often 
find,  in  a  case  which  is  progressing  apparently  well,  a  rise  of  tem- 
perature and  an  accession  of  febrile  symptoms,  followed  by  the  swell- 
ing of  the  other  limb. 

Progress  of  the  Disease. — -After  the  acute  stage  has  lasted  from  a 
week  to  a  fortnight,  the  constitutional  disturbance  becomes  less 
marked,  the  pulse  and  temperature  fall,  the  pain  abates,  and  the 
sleeplessness  and  restlessness  are  less.  The  swelling  and  tension  of 
the  limb  now  begin  to  diminish,  and  absorption  commences.  This  is 
invariably  a  slow  process.  It  is  always  many  weeks  before  the  effu- 
sion has  disappeared,  and  it  may  be  many  months.  The  limb  re- 
tains for  a  length  of  time  the  peculiar  loooden  feeling,  as  Dr.  Churchill 
terms  it.  Any  imprudence,  such  as  a  too  early  attempt  at  walking, 
may  bring  on  a  relapse  and  fresh  swelling  of  the  limb.  This  gradual 
recovery  is  by  far  the  most  common  termination  of  the  disease.  In 
some  rare  cases  suppuration  may  take  place,  either  in  the  subcuta- 
neous cellular  tissue,  the  lymphatic  glands,  or  even  in  the  joints,  and 
death  may  result  from  exhaustion.  The  possibility  of  pulmonary 
obstruction  and  sudden  death  from  separation  of  an  embolus  have 
already  been  pointed  out,  and  the  fact  that  this  lamentable  occurrence 
has  generally  followed  some  undue  exertion  should  be  borne  in  mind, 
as  a  guide  in  the  management  of  our  patient. 

Period  of  Commencement. — The  disease  usually  begins  within  a 
short  time  after  delivery,  rarely  after  the  second  week.  In  22  cases 
tabulated  by  Dr.  Robert  Lee,  7  were  attacked  between  the  fourth  and 
twelfth  days,  and  14  after  the  second  week.  Some  cases  have  been 
described  as  commencing  even  months  after  delivery.  It  is  question- 
able if  these  can  be  classed  as  puerperal,  for  it  must  not  be  forgotten 
that  phlegmasia  dolensis  by  no  means  necessarily  a  puerperal  disease. 
There  are  many  other  conditions  which  may  give  rise  to  it,  all  of 
them,  however,  such  as  produce  a  septic  and  hyperinosed  state  of  the 
blood,  such  as  malignant  disease,  dysentery,  phthisis,  and  the  like. 
My  own  experience  would  lead  me  to  think  that  cases  of  this  kind 
are  much  more  common  than  is  generally  believed. 

History  and  Pathology. — The  disease  has  long  attracted  the  atten- 
tion of  the  profession.     Passing  over  more  or  less  obscure  notices  by 


PERIPHERAL    VENOUS    THROMBOSIS,    ETC.  631 

Hippocrates,  Dc  Castro,  and  others,  we  find  the  first  clear  account  in 
the  writings  of  Mauriceau,  who  not  only  gave  a  very  accurate  de- 
scription of  its  symptoms,  but  made  a  guess  at  its  pathology,  which 
was  certainly  more  happy  than  the  speculations  of  his  successors ;  it 
is,  he  says,  caused,  ''by  a  reflux  on  the  parts  of  certain  humors 
which  ought  to  have  been  evacuated  by  the  lochia,"  Puzos  ascribed 
it  to  the  arrest  of  the  secretion  of  milk,  and  its  extravasation  in  the 
affected  limb.  This  theory,  adopted  by  Levrct  and  many  subsequent 
writers,  toolc  a  strong  hold  on  both  professional  and  public  opinion, 
and  to  it  we  owe  many  of  the  names  by  which  the  disease  is  known 
to  this  day,  such  as  oedema  lacteum,  milk  leg,  etc.  In  ITS-i  Mr. 
White,  of  Manchester,  attributed  it  to  some  morbid  condition  of 
the  lymphatic  glands  and  vessels  of  the  affected  parts ;  and  this,  or 
some  analogous  theory,  such  as  that  of  rupture  of  the  lymphatics 
crossing  the  pelvic  brim,  as  maintained  by  Tyre,  of  Gloucester,  or 
general  inflammation  of  the  absorbents  as  held  by  Dr.  Fcrriar,  was 
generally  adopted. 

Phlehiiic  Theory. — It  was  not  until  the  year  1823  that  attention  was 
drawn  to  the  condition  of  the  veins.  To  Bouillaud  belons-s  the  un- 
doubted  merit  of  first  pointing  out  that  the  veins  of  the  affected  limb 
were  blocked  up  by  coagula,  although  the  fact  had  been  previously 
observed  by  Dr.  Davis,  of  University  College.  Dr.  Davis  made  dissec- 
tions of  the  veins  in  a  fatal  case,  and  found,  as  Bouillaud  had  done, 
that  they  were  filled  with  coagula,  which  he  assumed  to  be  the 
results  of  inflammation  of  their  coats;  hence  the  name  of  ^'■crural 
phlehitis^''''  which  has  been  extensively  adopted  instead  of  phlegmasia 
dolens.  Dr.  Eobert  Lee  did  much  to  favor  this  view,  and  finding 
that  thrombi  were  present  in  the  iliac  and  uterine,  as  well  as  m  the 
femoral,  veins,  he  concluded  that  the  phlebitis  commenced  in  the 
uterine  branches  of  the  hj^pogastri^  veins,  and  extended  downwards 
to  the  femorals.  p[e  pointed  out  that  phlegmasia  dolens  was  not 
limited  to  the  puerperal  state  ;  but  that  when  it  did  occur  independ- 
ently of  it,  other  causes  of  uterine  phlebitis  were  present,  such  as 
cancer  of  the  os  and  cervix  uteri.  The  inflammatory  theory  was 
pretty  generally  received,  and  even  now  is  considered  by  many  to  be 
a  sufficient  explanation  of  the  disease.  Indeed  the  fact  that  more  or 
less  thrombus  was  always  present  could  not  be  denied,  and  on  the 
supposition  that  thrombus  could  only  be  caused  by  phlebitis,  as  was 
long  supposed  to  be  the  case,  the  inflammatory  theory  was  the  natural 
one.  Before  long,  however,  pathologists  pointed  oat  that  thrombosis 
was  by  no  means  necessarily,  or  even  generally,  the  result  of  inflam.- 
mation  of  the  vessels  in  which  the  clot  was  contained,  but  that  the 
inflammation  was  more  generally  the  result  of  the  coagulum. 

Theory  of  its  Dependence  on  Septic  Causes. — The  late  Dr.  Mackenzie 
took  a  prominent  part  in  opposing  the  phlebitic  theory.  He  proved, 
by  numerous  experiments  in  the  loAver  animals,  that  inflammation 
is  not  sufficient  of  itself  to  produce  the  extensive  thrombi  which  are 
found  to  exist,  and  that  inflammation  originating  in  one  part  of  a 
vein  is  not  apt  to  spread  along  its  canal,  as  the  phlebitic  theory 
assumes.     His  conclusion  is,  that  the  origin  of  the  disease  is  rather 


632  THE    PUERPERAL    STATE. 

to  be  sought  in  some  septic  or  altered  condition  of  the  blood,  pro- 
ducing coagulation  in  the  veins.  Dr.  Tyler  Smith^  pointed  out  an 
occasiooal  analogy  between  the  causes  of  phlegmasia  dolens  and  puer- 
peral fever,  eviaently  recognizing  the  dependence  of  the  former  on 
blood  dyscrasia.  "1  believe,"  he  says,  "that  contagion  and  infection 
play  a  very  important  part  in  the  production  of  the  disease.  I  look 
on  a  woman  attacked  with  phlegmasia  dolens  as  having  made  a 
fortunate  escape  from  the  greater  dangers  of  diffuse  phlebitis  or 
j)uerperal  fever."  In  illustration  of  this  he  narrates  the  following- 
instructive  history :  "A  short  time  ago  a  friend  of  mine  had  been  in 
close  attendance  on  a  patient  dying  of  erysipelatous  sore-throat  with 
sloughing,  and  was  himself  affected  with  sore-throat.  Under  these 
circumstances,  he  attended,  within  the  space  of  twenty-four  hours, 
three  ladies  in  their  conlinements,  all  of  whom  were  attacked  with 
phlegmasia  dolens." 

V-ieio  of  TilJmry  Fox. — The  latest  important  contribution  to  the 
pathology  of  the  disease  is  contained  in  two  papers  by  Dr.  Tilbury 
Fox,  published  in  the  second  volume  of  the  "  Obstetrical  Transac- 
tions." He  maintains  that  something  beyond  the  mere  presence  of 
coagula  in  the  veins  is  required  to  produce  the  phenomena  of  the 
disease,  although  he  admits  that  to  be  an  important,  and  even  an 
essential,  part  of  pathological  changes  present.  The  thrombi  he  be- 
lieves to  be  produced  either  by  extrinsic  or  intrinsic  causes :  the 
former  comprising  all  cases  of  pressure  by  tumor  or  the  like ;  the 
latter,  and  the  most  important,  being  divisible  into  the  heads  of — 

1.  True  inflammatory  changes  in  the  vessels,  as  seen  in  the  epi- 
demic form  of  the  disease. 

2.  Simple  thrombus,  produced  by  rapid  absorption  of  morbid 
fluid. 

3.  Yirus  action  and  thrombus  conjoined,  the  phlegmasia  dolens 
itself  being  the  result  of  simple  thrombus,  and  not  produced  by  dis- 
eased (inflamed)  coats  of  vessels  ;  the  general  symptoms  the  result  of 
the  general  blood-state ;  the  virus  present. 

He  further  points  out  that  the  peculiar  swelling  of  the  limbs  can- 
not be  explained  by  the  mere  presence  of  oedema,  from  which  it  is 
essentially  different.  The  white  appearance  of  the  skin,  the  severe 
neuralgic  pain,  and  the  persistent  numbness  indicating  that  the  whole 
of  the  cutaneous  textures,  the  cutis  vera  and  even  the  epithelial 
layer,  are  infiltrated  with  fibrinous  deposit.  He  concludes,  there- 
fore, that  the  swelling  is  the  result  of  oedema  73?^;s  something  else ; 
that  something  being  obstruction  of  the  lymphatics,  by  which  the 
absorption  of  effused  serum  is  prevented.  The  efficient  cause  which 
produces  these  changes  he  believes  to  be,  in  the  majority  of  cases, 
a  septic  action  originating  in  the  nterus,  producing  a  condition  sim- 
ilar to  that  in  which  phlegmasia  dolens  arises  in  the  non-puerperal 
state. 

There  is  no  doubt  much  force  in  Dr.  Fox's  arguments,  and  it  ma}^, 
I  think,  be  conceded  that  obstruction  of  the  veins  per  se  is  not  suffi- 

'  Tyler  Smith,  Manual  of  Obstetrics,  p.  538. 


PERIPHERAL    VENOUS    THROMBOSIS,    ETC.  683 

cient  to  produce  the  peculiar  appearance  of  the  limb.  It  is,  more- 
over, certain  tljat  phlebitis  alone  is  also  an  iut^ufficient  explanation 
not  only  of  the  symptoms,  but  even  of  the  presence  of  thrombi  so 
extensive  as  those  that  are  found.  Ihe  view  which  traces  the 
disease  solely  to  inflammation  or  obstruction  of  lymphatics  is  purely 
theoretical,  has  no  basis  of  facts  to  support  it,  and  hnds,  nowadays, 
no  supporters.  The  experiments  of  Mackenzie  and  Lee,  as  well  as 
the  vastly  increased  knowledge  of  the  causes  of  thrombosis  which 
the  researches  of  modern  pathologists  have  given  us,  seem  to  point 
strongly  to  the  view  already  stated,  that  the  disease  can  only  be 
explained  by  a  general  blood  dyscrasia,  depending  on  the  puerperal 
state.  It  by  no  means  follows  that  we  are  to  consider  Dr.  Fox's 
speculations  as  incorrect.  It  is  far  from  improbable  tbat  the  lym- 
])hatic  vessels  are  implicated  in  the  production  of  the  peculiar  swell- 
ing, only  we  are  not  as  yet  in  a  position  to  prove  it.  There  is  no 
inherent  improbabihty  in  the  supposition  that  the  same  morbid 
state  of  the  blood  which  produces  thrombosis  in  the  veins,  may  also 
give  rise  to  such  an  amount  of  irritation  in  the  lymphatics  as  may 
interfere  with  their  functions,  and  even  obstruct  them  altogether. 
The  essential  and  all-important  point  in  the  pathology  of  the  disease, 
however,  seems  undoubtedly  to  be  thrombosis  in  the  veins;  and  the 
probability  of  there  being  some  as  yet  undetermined  pathological 
changes  in  addition  to  this,  by  no  means  militates  against  the  view 
I  have  taken  of  the  intimate  connection  of  the  disease  with  other 
results  of  thrombosis  in  different  vessels. 

Ghanyes  Occurring  in  the  ThromM. — The  changes  which  take  place 
in  the  thrombi  all  tend  to  their  ultimate  absorption.  These  have 
been  described  by  various  authors  as  leading  to  organization  or  sup- 
puration. It  is  probable,  however,  that  the  appearances  which  have 
led  to  such  a  supposition  are  fallacious,  and  that  they  are  really  due 
to  retrograde  metamorphosis  of  the  fibrine,  generally  of  an  amyla- 
ceous or  fatty  character. 

Detachment  of  SmhoU.— The  peculiarities  of  a  clot  that  most  favor 
detachment  of  an  embolus  are  such  a  shape  as  admits  of  a  portion 
floating  freely  in  the  blood-current,  by  the  force  of  which  it  is  de- 
tached and  carried  to  its  ultimate  destination.  When  the  accident 
has  occurred,  it  is  often  possible  to  recognize  the  peripheral  thrombus 
from  which  the  embolus  has  separated,  by  the  fact  of  its  terminal 
extremity  presenting  a  freshly  fractured  end,  instead  of  the  rounded 
head  natural  to  it.  Such  detachment  is  unlikely  to  occur,  even  when 
favored  b}^  the  shape  of  the  clot,  unless  sufficient  time  have  elapsed 
after  its  formation  to  admit  of  its  softening  and  becoming  brittle. 
The  curious  fact  I  have  before  mentioned,  of  true  puerperal  embo- 
lism occurring,  in  the  large  majority  of  cases,  only  after  the  nine- 
teenth day  from  delivery,  finds  a  ready  explanation  in  this  theory, 
which  it  remarkably  corroborates. 

Treatment. — On  the  supposition  that  phlegmasia  dolens  was  the 
result  of  inflammation  of  the  veins  of  the  affected  limb,  an  antiphlo- 
gistic course   of  treatment  was    naturally    adopted.      Accordingly, 
most  writers  on  the  subject  recommended  depletion,  generally  by  the 
41 


634  THE    PUERPERAL    STATE. 

application  of  leeches,  along  the  course  of  the  affected  vessels.  We 
are  told  that  if  the  pain  continue  the  leeches  should  be  applied  a 
second,  or  even  a  third  time.  If  we  admit  the  septic  origin  of  the 
disease  we  must,  I  think,  see  the  impropriety  of  such  a  practice. 
The  fact  that  it  occurs,  in  a  large  majority  of  cases,  in  patients  of  a 
weakly  and  debilitated  constitution,  often  in  women  who  have  already 
suffered  from  hemorrhage,  is  a  further  reason  for  not  adopting  this 
routine  custom.  If  local  loss  of  blood  be  used  at  all,  it  should  be 
strictly  limited  to  cases  in  which  there  is  much  tenderness  and  red- 
ness along  the  course  of  the  veins,  and  then  only  in  patients  of  ple- 
thoric habit  and  strong  constitution  ;  cases  of  this  kind  will  form  a 
very  small  minority  of  those  coming  under  our  observation. 

Over-active  Treatment  Unadvisahle. — AVhat  has  been  said  of  the 
pathology  of  the  affection  tends  to  the  conclusion  that  active  treat- 
ment of  any  kind,  in  the  hope  of  curing  the  disease,  is  likely  to  be 
useless.  Our  chief  reliance  must  be  on  time  and  perfect  rest,  in 
order  to  admit  of  the  thrombi  and  the  secondary  effusion  being  ab- 
sorbed ;  Avhile  we  relieve  the  pain  and  other  prominent  symptoms, 
and  support  the  strength  and  improve  the  constitution  of  the  patient. 

Relief  of  Pai7i,  etc. — The  constant  application  of  heat  and  moisture 
to  the  affected  limb  will  do  much  to  lessen  tlie  tension  and  pain. 
"Wrapping  the  entire  limb  in  linseed-meal  poultices,  frequently 
changed,  is  one  of  the  best  means  of  meeting  this  indication.  If,  as 
is  sometimes  the  case,  the  weight  of  the  poultices  be  too  great  to  be 
readily  borne,  we  may  substitute  warm  llannel  stupes,  covered  with 
oiled  silk.  Local  anodyne  applications  afford  much  relief,  and  may 
be  advantageously  used  along  with  the  poultices  and  stupes,  either 
by  sprinkling  their  surface  freely  with  laudanum,  or  chloroform  and 
belladonna  liniment,  or  by  soaking  the  flannels  in  poppy-head  fomen- 
tation. It  is  needless  to  say  that  the  most  absolute  rest  in  bed  should 
be  enjoined,  even  in  slight  cases,  and  that  the  limb  should  be  effectu- 
ally guarded  from  undue  pressure  by  a  cradle  or  some  similar  con- 
trivance. Local  counter-irritation  has  been  strongly  recommended, 
and  frequent  blisters  have  been  considered  by  some  to  be  almost 
specific.  I  should  myself  hesitate  to  use  blisters,  as  they  would 
certainly  not  be  soothing  applications,  and  one  hardly  sees  how  they 
can  be  of  much  service  in  hastening  the  absorption  of  the  effusion. 

Constitntional  Treatm.ent. — During  the  acute  stage  of  the  disease 
the  constitutional  treatment  must  be  regulated  by  the  condition  of 
the  patient.  Light,  but  nutritious  diet,  must  be  administered  in 
abundance,  such  as  milk,  beef-tea,  and  soups.  Should  there  be  much 
debility,  stimulants,  in  moderation,  may  prove  of  service.  With 
regard  to  medicines,  we  shall  probably  find  benefit  from  such  as  are 
calculated  to  improve  the  condition  of  the  blood  and  the  general 
health  of  the  patient.  Chlorate  of  potash,  with  diluted  hydrochloric 
acid,  quinine,  either  alone  or  in  combination  with  sesquicarbonate  of 
ammonia,  the  tincture  of  the  perchloride  of  iron,  are  the  drugs  that 
are  most  likely  to  prove  of  service.  Alkalies  and  other  medicines, 
which  have  been  recommended  in  the  hope  of  hastening  tlie  absorp- 
tion of  coagula,  must  be  considered  as  altogether  useless.    Pain  must 


PERIPHERAL    VENOUS    THROMBOSIS,    ETC.  635 

be  relieved  and  sleep  produced  by  the  judicious  use  of  anodynes, 
such  as  Dover's  powder,  the  subcutaneous  injection  of  morphia,  or 
chloral.  Generally  no  form  answers  so  well  as  the  hypodermic  in- 
jection of  morphia. 

Subsequent  Local  Treatment. — When  the  acute  symptoms  have 
abated,  and  the  temperature  has  fallen,  the  poultices  and  stupes  may 
be  discontinued,  and  the  limb  swathed  in  a  flannel  roller  from  the 
toes  upwards.  The  equable  pressure  and  support  thus  afforded  ma- 
terially aid  the  absorption  of  the  effusion,  and  tend  to  diminish  the 
size  of  the  limb.  At  a  still  later  stage  very  gentle  inunctions  of 
weak  iodine  ointment  may  be  used  with  advantage  once  a  day  before 
the  roller  is  applied.  Shampooing  and  friction  of  the  limb,  generally 
recommended  for  the  purpose  of  hastening  absorption,  should  be 
carefully  avoided,  on  account  of  the  possible  risk  of  detaching  a 
portion  of  the  coagulum,  and  producing  embolism.  Tliis  is  no 
merely  imaginary  danger,  as  the  following  fact  narrated  by  Trousseau 
proves,  "A  phlegmasia  alba  dolens  had  appeared  on  the  left  side  in 
a  young  Avoman  suffering  from  peri-uterine  phlegmon.  The  pain 
having  ceased,  a  thickened  venous  trunk  was  felt  on  the  upper  and 
internal  part  of  the  thigh.  Eather  strong  pressure  was  being  made, 
when  M.  Demarquay  felt  something  yield  under  his  fingers.  A  few 
minutes  afterwards  the  patient  was  attacked  with  dreadful  palpita- 
tion, tumultuous  cardiac  iiction,  and  extreme  pallor,  and  death  was 
believed  to  be  imminent.  After  some  hours,  however,  the  oppression 
ceased,  and  the  patient  eventually  recovered.  A  slightly  attached 
coagulum  must  have  become  separated,  and  conveyed  to  the  heart 
or  pulmonary  artery."'  Warm  douches  of  Avater,  of  salt  water  if  it 
can  be  obtained,  may  be  advantageously  used  in  the  later  stages  of 
the  disease,  and  they  may  be  applied  night  and  morning,  the  limb 
being  bandaged  in  the  interval.  The  occasional  use  of  the  electric 
current  is  said  to  promote  absorption,  and  would  seem  likely  to  be  a 
serviceable  remedy. 

Change  of  Air,  etc. — When  the  patient  is  well  enough  to  be  moved, 
a  change  of  air  to  the  seaside  will  be  of  value.  Great  caution,  how- 
ever, should  be  recommended  in  using  the  limb,  and  it  is  far  better 
not  to  run  the  risk  of  a  relapse  by  any  undue  haste  in  this  respect. 
It  is  well  to  warn  the  patient  and  her  friends,  that  a  considerable 
time  must  of  necessity  elapse,  before  the  local  signs  of  the  disease 
have  completely  disappeared. 

'  Trousseau,  Clinique  cle  I'Hotel-Dieu  in  Gaz.  des  Hop.,  1860,  p.  577. 


636  THE    PUERPERAL    STATE. 


CHAPTER  X. 

PELVIC  CELLULITIS  AND  PELVIC  PERITONITIS, 

From  the  earliest  time  the  occurrence  after  parturition  of  severe 
forms  of  inflammatory  disease  in  and  about  the  pelvis,  frequently 
ending  in  suppuration,  has  been  well  known.  It  is  only  of  late  years, 
however,  that  these  diseases  have  been  made  the  subject  of  accurate 
clinical  and  pathological  investigation,  and  that  their  true  nature  has 
begun  to  be  understood.  Nor  is  our  "knowledge  of  them  as  yet  by 
any  means  complete.  They  merit  careful  study  on  the  part  of  the 
accoucheur,  for  they  give  rise  to  some  of  the  most,  severe  and  pro- 
tracted illnesses  from  which  puerperal  patients  suffer.  They  are 
often  obscure  in  their  origin  and  apt  to  be  overlooked,  and  they  not 
rarely  leave  behind  them  lasting  mischief. 

These  diseases  are  not  limited  to  the  puerperal  state.  On  the  con- 
trary, many  of  the  severest  cases  arise  from  causes  altogether  uncon- 
nected with  child-bearing.  These  will  not  be  now  considered,  and 
this  chapter  deals  solely  with  such  forms  as  may  be  directly  traced 
to  child-birth. 

Two  Distirtct  Forms. — Eecent  researches  have  demonstrated  that 
there  are  two  distinct  varieties  of  inflammatory  disease  met  with 
after  labor,  which  differ  materiall}^  from  each  other  in  many  respects. 
In  one  of  these,  the  inflammation  affects  chiefly  the  connective  tissue 
surrounding  the  generative  organs  contained  within  the  pelvis,  or 
extends  up  from  beneath  the  peritoneum,  and  into  the  iliac  fossae. 
In  the  other,  it  attacks  that  portion  of  the  peritoneum  which  covers 
the  pelvic  viscera,  and  is  limited  to  it. 

So  much  is  admitted  by  all  writers,  but  great  obscuritj^  in  descrip- 
tion, and  consequent  difficulty  in  understanding  satisfactorily  the 
nature  of  these  affections,  have  resulted  from  the  variety  of  nomen- 
clature which  different  authors  have  adopted. 

Thus  the  former  disease  has  been  variously  described  as  pelvic 
cellulitis,  peri-uterine  phlegmon,  para-metritis,  or  pelvic  abscess, 
while  the  latter  is  not  unfrequently  called  peri-metritis,  as  contra- 
distinguished from  para-metritis.  The  use  of  the  prefix  jjara  or  peri ^ 
to  distinguish  the  cellular  or  peritoneal  variety  of  inflammation, 
originally  suggested  by  Virchow,  has  been  pretty  generally  adopted 
in  Germany,  and  has  been  strongly  advocated  in  this  country  by 
Matthews  Duncan.  It  has  never,  however,  found  much  favor  with 
English  writers,  and  the  similarity  of  the  two  names  is  so  great  as  to 
lead  to  confusion.  I  have,  therefore,  selected  the  terms  '■'pelvic  peri- 
tonitis,^'' and  '■'■pelvic  cellulitis,''''  as  conveying  in  themselves  a  fairly 
accurate  notion  of  the  tissues  mainly  involved. 


PELVIC    CELLULITIS    AND    PELVIC    PERITONITIS.  637 

Imjwrtance  of  Distinyuislting  the  Two  Classes  of  Cases. — The  im- 
portant fact  to  I'einember  is  that  there  exist  two  distinct  varieties  of 
inflammatory  disease,  presenting  many  similarities  in  their  course, 
symptoms,  and  results,  often  occurring  simultaneously,  but  in  the 
main  distinct  in  their  pathology,  and  capable  of  being  differentiated. 
Thomas  compares  them — and,  as  serving  to  fix  the  facts  on  the 
memory,  the  illustration  is  a  good  one — to  pleurisy  and  pneumonia. 
"  Like  them,"  he  says,  "  they  are  separate  and  distinct,  like  them 
affect  different  kinds  of  structure,  and  like  them  they  generally  com- 
plicate each  other."  It  might,  therefore,  be  advisable,  as  most 
writers  on  the  disease  occurring  in  the  non-puerperal  state  have 
done,  to  treat  of  them  in  two  separate  chapters.  There  is,  however, 
more  difficulty  in  distinguishing  them  as  puerperal  than  as  non-puer- 
peral affections,  for  which  reason,  as  well  as  for  the  sake  of  brevity, 
I  think  it  better  to  consider  them  together,  pointing  out,  as  I  pro- 
ceed, the  distinctive  peculiarities  of  each. 

Seat  of  Disease. — When  attention  was  first  directed  to  this  class  of 
diseases,  the  pelvic  cellular  tissue  was  believed  to  be  the  only  struc- 
ture affected.  This  was  the  view  maintained  by  Nonat,  Simpson, 
and  many  modern  writers.  Attention  was  first  prominent!}^  directed 
to  the  importance  of  localized  inflammation  of  the  peritoneum,  and 
to  the  fact  that  many  of  the  supposed  cases  of  cellulitis  were  really 
peritonitic,  by  Bernutz.  There  can  be  no  doubt  that  he  here  made 
an  enormous  step  in  advance.  Like  many  authors,  however,  he  rode 
his  hobby  a  little  too  hard,  and  he  erred  in  denying  the  occurrence 
of  cellulitis  in  many  cases  in  which  it  undoubtedly  exists. 

Etiology. — The  great  influence  of  child-birth  in  producing  these 
diseases  has  long  been  fully  recognized.  Courty  estimates  that  about 
two-thirds  of  all  the  cases  met  with  occur  in  connection  with  de- 
livery or  abortion,  and  Duncan  found  that  out  of  40  carefully  observed 
cases,  25  were  associated  with  the  puerperal  state. 

The  Inflammation  is  Secondary  and  never  Idioj>aihic. — It  is  pretty 
generally  admitted  by  most  modern  writers  that  both  varieties  of  the 
disease  are  produced  by  the  extension  of  inflammation  from  either 
the  uterus,  the  Fallopian  tubes,  or  the  ovaries.  This  point  has  been 
especially  insisted  on  by  Duncan,  who  maintains  that  the  disease  is 
never  idiopathic,  and  is  "  invariably  secondary  either  to  mechanical 
injury,  or  to  the  extension  of  inflammation  of  some  of  the  pelvic  vis- 
cera, or  to  the  irritation  of  the  noxious  discharges  through  or  from 
the  tubes  or  ovaries." 

Often  intimately  connected  with  Septicsemia . — Their  intimate  con- 
nection with  puerperal  septicsemia  is  also  a  prominent  fact  in  the 
natural  history  of  the  diseases.  Barker  mentions  a  curious  observa- 
tion illustrative  of  this,  that  when  puerperal  fever  is  endemic  in  the 
Bellevue  Hospital  in  New  York,  cases  of  pelvic  peritonitis  and  cel- 
lulitis are  also  invariably  met  with.  Olshausen  has  also  remarked 
that  in  the  Lying-in  Hospital  at  Halle,  during  the  autumn  vacation, 
when  the  patients  are  not  attended  by  practitioners,  and  when,  there- 
fore, the  chance  of  septic  infection  being  conveyed  to  them  is  less, 
these  inflammations  are  almost  always  absent.     As  inflammation  of 


638  THE    PUERPERAL    STATE. 

the  lining  membrane  of  the  uterus,  of  the  vaginal  mucous  membrane, 
and  of  the  pelvic  connective  tissue,  are  of  very  constant  occurrence 
as  loca]  phenomena  of  septic  absorption,  the  connection  between  the 
two  classes  of  cases  is  readily  susceptible  of  explanation.  Schroeder, 
indeed,  goes  further,  and  includes  his  description  of  these  dis- 
eases under  the  head  of  puerperal  fever.  They  do  not,  however, 
necessarily  depend  upon  it;  for,  although  it  must  be  admitted  that 
cases  of  this  kind  form  a  large  proportion  of  those  met  with,  others 
unquestionably  occur  which  cannot  be  traced  to  such  sources,  but  are 
the  direct  result  of  causes  altogether  unconnected  with  the  inflam- 
mation attending  on  septic  absorption,  such  as  undue  exertion  shortlv 
after  delivery,  or  premature  coition.  Mechanical  causes  may  beyond 
doubt  excite  the  disease  in  a  woman  predisposed  by  the  puerperal 
process,  but  they  cannot  fairly  be  included  under  the  head  of  puer- 
peral fever. 

Seat  of  the  Inflammation  171  Pelvic  Cellulitis. — Abundance  of  areolar 
tissue  e-xists  in  connection  with  the  pelvic  viscera,  which  may  be  the 
seat  of  cellulitis.  It  forms  a  loose  padding  between  the  organs  con- 
tained in  the  pelvis  proper,  surrounds  the  vagina,  the  rectum,  and 
the  bladder,  and  is  found  in  considerable  quantity  between  the  folds 
of  the  broad  ligaments.  From  these  parts  it  extends  upwards  to  the 
iliac  fossse,  and  the  inner  surface  of  the  abdominal  parietes.  In  any 
of  these  positions  it  may  be  the  seat  of  the  kind  of  inflammation  we 
are  discussing.  The  essential  character  of  the  inflammation  is  similar 
to  that  which  accompanies  areolar  inflammation  in  other  parts  of  the 
body.  There  is  first  an  acute  inflammatory  oedema,  followed  by  the 
infiltration  of  the  areolae  of  the  connective  tissue  with  exudation, 
and  the  consequent  formation  of  appreciable  swellings.  These  may 
form  in  any  part  of  the  pelvis.  Thus  we  may  meet  with  them,  and 
this  is  a  very  common  situation,  between  the  folds  of  the  broad 
ligaments,  forming  distinct  hard  tumors,  connected  with  the  uterus, 
and  extending  to  the  pelvic  walls,  their  rounded  outlines  being  readily 
made  out  by  bi-manual  examination.  If  the  cellulitis  be  limited  in 
extent,  such  a  swelling  may  exist  on  one  side  of  the  uterus  only, 
forming  a  rounded  mass  of  varying  size,  and  apparently  attached  to 
it.  At  other  times  the  exudation  is  more  extensive,  and  may  com- 
pletely or  partially  surround  the  uterus,  extending  to  the  cellular 
tissue  between  the  vagina  and  rectum,  or  between  the  uterus  and 
the  bladder.  In  such  cases  the  uterus  is  imbedded  and  firmly  fixed 
in  dense  hard  exudation.  At  other  times,  the  inflammation  chiefly 
affects  the  cellular  tissue  covering  the  muscles  lining  the  iliac  fossse. 
There  it  forms  a  mass,  easily  made  out  by  palpation,  but  on  vaginal 
examination  little  or  no  trace  of  the  exudation  can  be  felt,  or  only  a 
sense  of  thickness  at  the  roof  of  the  vagina  on  the  same  side  as  the 
swelling. 

Seat  of  the  Inflaramation  in  Pelvic  Peritonitis. — In  pelvic  peritonitis 
the  inflammation  is  limited  to  that  portion  of  the  peritoneum  which 
invests  the  pelvic  viscera.  Its  extent  necessarily  varies  with  the 
intensity  and  duration  of  the  attack.  In  some  cases  there  may  be 
little  more  than  irritation,  while  more  often  it  runs  on  to  exudation 


PELVIC    CELLULITIS    AND    PELVIC    PERITONITIS.  Gii9 

of  plastic  material.  The  result  is  generally  complete  fixation  of  the 
uterus,  and  liardening  and  swelling  in  the  root  of  tlic  vagina,  and 
tlie  lymph  poured  out  may  mat  together  the  surrounding  viscera,  so 
as  to  form  swellings,  difficult,  in  some  cases,  to  diiferentiate  from 
those  resulting  from  cellulitis.  On  post-mortem  examination  the 
pelvic  viscera  are  found  extensively  adherent,  and  the  agglutination 
may  involve  the  coils  of  the  intestine  in  the  vicinity,  so  as  sometimes 
to  form  tumors  of  considerable  size. 

Relative  Frequency  of  ilte  Two  Forms  of  Disease. — The  relative  fre- 
quency of  these  two  forms  of  inflammation  as  puerperal  affections  is 
not  easy  to  ascertain.  In  the  non-puerperal  state  the  peritonitic 
variety  is  much  the  more  common,  but  in  the  puerperal  state  they 
very  generally  complicate  each  other,  and  it  is  rare  for  cellulitis  to 
exist  to  any  great  extent  without  more  or  less  peritonitis. 

Symptomatoloyy . — The  earliest  symptom  is  pain  in  the  lower  part 
of  the  abdomen,  which  is  generally  preceded  by  rigor  or  chilliness. 
The  amount  of  .pain  varies  much.  Sometimes  it  is  comparatively 
slight,  and  it  is  by  no  means  rare  to  meet  with  patients,  who  are  the 
subjects  of  very  considerable  exudations,  who  suffer  little  more  than 
a  certain  sense  of  weight  and  discomfort  at  the  lower  part  of  the 
abdomen.  On  the  other  hand  the  suffering  may  be  excessive,  and  is 
characterized  by  paroxysmal  exacerbations,  the  patient  being  com- 
paratively free  from  pain  for  several  successive  hours,  and  then 
having  attacks  of  the  most  acute  agony.  Schroeder  says  that  pain 
is  always  a  symptom  of  peritonitis,  and  that  it  does  not  exist  in 
uncomplicated  cellulitis.  The  swellings  of  cellulitis  are  certainly 
sometimes  remarkably  free  from  tenderness,  and  I  have  often  seen 
masses  of  exudation  in  the  iliac  fossae,  which  could  bear  even  rough 
handling.  On  the  other  hand,  although  this  is  certainly  more  often 
met  with  in  non- puerperal  cases,  the  tenderness  over  the  abdomen  is 
sometimes  excessive,  the  patient  shrinking  from  the  slightest  touch. 
The  pulse  is  raised,  generally  from  100  to  120,  and  the  thermometer 
shows  the  presence  of  pyrexia.  During  the  entire  course  of  the 
disease  both  these  sjmiptoms  continue.  The  temperature  is  often 
very  high,  but  more  frequently  it  varies  from  100 "^  to  10-1°,  and  it 
generally  shows  more  or  less  marked  remissions.  In  some  cases  the 
temperature  is  said  not  to  be  elevated  at  all,  or  even  to  be  sub-nor- 
mal, but  this  is  certainly  quite  exceptional.  Other  signs  of  local 
and  general  irritation  often  exist.  Among  them,  and  most  distinctly 
in  cases  of  peritonitis,  are  nausea  and  vomiting,  and  an  anxious 
pinched  expression  of  the  countenance,  while  the  local  mischief  often 
causes  distressing  dysuria  and  tenesmus.  The  latter  is  especially 
apt  to  occur  when  there  is  exudation  between  the  rectum  and  vagina, 
which  presses  on  the  bowel.  The  passage  of  feces,  unless  in  a  very 
liquid  form,  may  then  cause  intolerable  suffering. 

Such  symptoms  may  show  themselves  within  a  few  days  after 
delivery,  and  then  they  can  barely  fail  to  attract  attention.  ""  On  the 
other  hand,  thev  may  not  commence  for  some  weeks  after  labor,  and 
then  they  are  often  insidious  in  their  onset,  and  apt  to  be  overlooked. 
It  is  far  from  rare  to  meet  with  cases  six  weeks  or  more  after  con. 


64:0  THE    PUERPERAL    STATE. 

finement,  in  whicli  the  patient  complains  of  little  beyond  a  feeling 
of  malaise  and  discomfort,  and  in  which,  on  investigation,  a  consid- 
erable amount  of  exudation  is  detected,  which  had  previously  entirely 
escaped  observation. 

Results  of  Physical  Examination.— ^On  introducing  the  finger  into 
the  vagina  it  will  be  found  to  be  hot  and  swollen,  in  some  cases  dis- 
tinctly oedematous,  and  on  reaching  the  vaginal  cul-de  sac  the  exist- 
ence of  exudation  may  generally  be  made  out.  The  amount  of  this 
varies  much.  Sometimes,  especially  in  the  early  stage  of  the  disease, 
there  is  little  more  than  a  dilfuse  sense  of  thickness  and  induration 
at  either  side  of,  or  behind,  the  uterus.  More  generally  careful 
bi-manual  examination  enables  us  to  detect  a  distinct  hardening  and 
swelling,  possibly  a  tumor  of  considerable  size,  which  may  appa- 
rently be  attached  to  the  sides  of  the  uterus,  and  rise  above  the 
pelvic  brim,  or  may  extend  quite  to  the  pelvic  walls.  The  examina- 
tion should  be  very  carefully  and  systematically  conducted  with 
both  hands,  so  as  to  explore  the  whole  contour  of  the  uterus  before, 
behind,  and  on  either  side,  as  well  as  the  iliac  fossae ;  otherwise  a 
considerable  exudation  might  readily  escape  detection.  When  the 
exudation  is  at  all  great,  more  or  less  fixity  of  the  uterus  is  sure  to 
exist,  and  is  a  very  characteristic  symptom.  The  womb,  instead  of 
being  freely  movable  by  the  examining  finger,  is  firmly  fixed  by  the 
surrounding  exudation,  and  in  severe  forms  of  the  disease  is  quite 
encased  in  it.  More  or  less  displacement  of  the  organ  is  also  of 
common  occurrence.  If  the  swelling  be  limited  to  one  side  of  the 
pelvis  or  to  Douglas's  space,  the  uterus  is  displaced  in  the  opposite 
direction,  so  that  it  is  no  longer  in  its  usual  central  position. 

The  Two  Forms  of  Disease  cannot  always  he  Distinyvished. — The 
differential  diagnosis  of  pelvic  cellulitis  and  pelvic  peritonitis  cannot 
always  be  made,  and,  indeed,  in  many  cases  it  is  impossible,  since 
both  varieties  of  disease  coexist.  The  elements  of  differentiation 
generally  insisted  on  are,  the  greater  general  disturbance,  nausea, 
etc.,  in  pelvic  peritonitis,  with  an  earlier  commencement  of  the  symp- 
toms after  labor.  The  swellings  of  pelvic  peritonitis  are  also  more 
tender,  with  less  clearly-defined  outline  than  those  of  cellulitis. 
"When  the  cellulitis  involves  the  iliac  fossa  the  diagnosis  is,  of  course, 
easy,  and  then  a  continuous  retraction  of  the  thigh  on  the  affected 
side  (an  involuntary  position  assumed  with  the  view  of  keeping  the 
muscles  lining  the  iliac  fossa  at  rest),  is  often  observed.  When  the 
inflammation  is  chiefly  limited  to  the  cavity  of  the  pelvis,  the  dis- 
tinction between  the  two  classes  of  cases  cannot  be  made  with  any 
degree  of  certainty. 

Terminations. — Both  forms  of  disease  may  end  either  in  resolution 
or  in  suppuration.  In  the  former  case,  after  the  acute  symptoms 
have  existed  for  a  variable  time,  it  may  be  for  a  few  days  only,  it 
may  be  for  many  weeks,  their  severity  abates,  the  swellings  become 
less  tender  and  commence  to  contract,  become  harder,  and  are  gradu- 
ally absorbed;  until,  at  last,  the  fixity  of  the  uterus  disappears,  and 
it  again  resumes  its  central  position  in  the  pelvic  cavity.  This  pro- 
cess is  often  very  gradual.     It  is  by  no  means  rare  to  find  a  patient, 


PELVIC    CELLULITIS    AND    PELVIC    PERITONITIS.  641 

even  some  months  after  the  attack,  when  all  acute  symptoms  have 
long  disappeared,  who  is  even  able  to  move  about  without  incon- 
venience, in  whom  the  uterus  is  still  immovably  fixed  in  a  mass  of 
deposit,  or  is,  at  least,  adherent  in  some  part  of  its  contour.  More 
or  less  permanent  adhesions  are  of  common  occurrence,  and  give 
rise  to  symptoms  of  considerable  obscurity,  which  are  often  not 
traced  to  their  proper  source. 

Symptoms  of  Suppuration. — When  the  inflammation  is  about  to 
terminate  in  suppuration,  the  pyrexial  symptoms  continue,  and 
eventually  well-marked  hectic  is  developed,  the  temperature  gene- 
rally showing  a  distinct  exacerbation  at  night.  At  the  same  time 
rigors,  loss  of  appetite,  a  peculiar  yellowish  discoloration  of  the  face, 
and  other  signs  of  suppuration,  show  themselves.  The  relative  fre- 
quency of  this  termination  is  variously  estimated  by  authors.  Duncan 
quotes  Simpson  as  calculating  it  as  occurring  in  half  the  cases  of 
pelvic  cellulitis,  but  states  his  own  belief  that  it  is  much  more  frequent. 
West  observed  it  in  23  out  of  43  cases  following  delivery  or  abor- 
tion, and  McClintock  in  37  out  of  70,  Schroeder  says  that  he  has 
only  once  seen  suppuration  in  92  cases  of  distinctly  demonstrable 
exudation,  a  result  which  is  certainly  totally  opposed  to  common 
experience.  Barker  also  states  that  in  his  experience  suppuration 
in  either  pelvic  peritonitis  or  cellulitis  "  is  very  rare,  except  when 
they  are  associated  with  pyeemia  or  puerperal  fever."  It  is  certaii; 
that  suppuration  is  more  likely  to  occur  in  pelvic  cellulitis  than  in 
pelvic  peritonitis,  but  it  unquestionably  occurs,  in  this  country  at 
least,  much  more  frequently  than  the  statements  of  either  of  these 
authors  would  lead  us  to  suppose. 

Channels  through  ichich  Pus  may  Escape. — The  pus  may  find  an 
exit  through  various  channels.  In  pelvic  cellulitis,  more  especially 
when  the  areolar  tissue  of  the  iliac  fossa  is  implicated,  the  most 
common  site  of  exit  is  through  the  abdominal  wall.  It  may,  how- 
ever, open  at  other  positions,  and  the  pus  may  find  its  way  through 
the  cellular  tissue  and  point  at  the  side  of  the  anus,  or  in  the  vagina, 
or  it  may  take  even  a  more  tortuous  course  and  reach  the  inner  sur- 
face of  the  thigh.  Pelvic  abscesses  not  uncommonly  open  into  the 
rectum  or  bladder,  causing  very  considerable  distress  from  tenesmus 
or  dysuria.  According  to  Hervieux,  it  is  chiefly  the  peritoneal 
varieties  which  open  in  this  way.  Not  unfrequently  more  than  one 
opening  is  formed;  and  when  the  pus  has  burrowed  for  any  dis- 
tance, long  fistulous  tracts  result,  which  secrete  pus  for  a  length  of 
time,  and  are  very  slow  to  heal.  Rupture  of  an  abscess  into  the 
peritoneal  cavity,  especially  of  a  peritonitic  abscess,  is  a  possible 
(but  fortunately  a  very  rare)  termination,  and  will  generally  prove 
fatal  by  producing  general  peritonitis.  In  one  case  which  I  have 
recorded  in  the  fifteenth  volume  of  the  "Obstetrical  Transactions," 
suppuration  was  followed  by  extensive  necrosis  of  the  pelvic  bones. 
Two  similar  cases  are  related  by  Trousseau  in  his  "  Clinical  Medi- 
cine," but  I  have  not  been  able  to  meet  with  any  other  examples  of 
this  rare  complication,  which  was  probably  rather  the  result  of  some 
obscure  septicEeraic  condition  than  of  extension  of  the  inflammation. 


642  THE    PUERPERAL    STATE. 

Prognosis. — The  prognosis  is  favorable  as  regards  ultimate  re- 
covery, but  there  is  great  risk  of  a  protracted  illness  which  may 
seriously  impair  the  health  of  the  patient,  especially  if  suppuration 
result.  Hence  it  is  necessary  to  be  guarded  in  an  expression  of 
opinion  as  to  the  consequences  of  the  disease.  Secondary  mischief 
is  also  far  from  unlikely  to  follow,  from  the  physical  changes  pro- 
duced b}^  the  exudation,  such  as  permanent  adhesions  or  malpositions 
of  the  uterus,  or  organic  alterations  in  the  ovaries  or  Fallopian  tubes. 

Treatment. — In  tiie  treatment  of  both  forms  of  disease  the  import- 
ant points  to  bear  in  mind,  are  the  relief  of  pain,  and  the  necessity 
of  absolute  rest;  and  to  these  objects  all  our  measures  must  be  sub- 
ordinate, since  it  is  quite  hopeless  to  attempt  to  cut  short  the  inflam- 
mation by  any  active  medication. 

If  the  disease  be  recognized  at  a  very  early  stage,  the  local  abstrac- 
tion of  blood,  by  the  application  of  a  few  leeches  to  the  groin  or  to  the 
hemorrhoidal  veins,  mav  give  relief;  but  the  influence  of  this  remedy 
has  been  greatly  exaggerated,  and  when  the  disease  is  of  any  standing- 
it  is  quite  useless.  Leeches  to  the  uterus,  often  recommended,  are,  I 
believe,  likel}^  to  do  more  harm  than  good  (unless  in  very  skilful 
hands),  from  the  irritation  produced  by  passing  the  speculum.  Opi- 
ates in  large  doses  may  be  said  to  be  our  sheet  anchor  in  treatment 
whenever  the  pain  is  at  all  severe,  either  by  the  mouth,  in  the  form 
of  morphia  suppositories,  or  injected  subcutaneously.  In  the  not 
uncommon  cases  in  which  pain  comes  on  severely  in  paroxysms,  the 
opiates  should  be  administered  in  sufl&cient  quantity  to  lull  the  pain, 
and  it  is  a  good  plan  to  give  the  nurse  a  supply  of  morphia  supposi- 
tories (which  often  act  better  than  any  other  form  of  administering 
the  drug),  with  directions  to  use  them  immediately  the  pain  threatens 
to  come  on.  When  there  is  much  pyrexia  large  doses  of  quinine 
may  be  given  with  great  advantage,  along  with  the  opiates.  The 
state  of  the  bowels  requires  careful  attention.  The  opiates  are  apt 
to  produce  constipation,  and  the  passage  of  hardened  feces  causes 
much  suffering.  Hence  it  is  desirable  to  keep  the  bowels  freely 
open.  Nothing  answers  this  purpose  so  well  as  small  doses  of  castor 
oil,  such  as  half  a  teaspoonful  given  every  morning.  Warmth  and 
moisture,  constantly  applied  to  the  lower  part  of  the  abdomen,  give 
great  relief  either  in  the  form  of  large  poultices  of  linseed  meal,  or, 
if  these  prove  too  heavy,  of  spongio-piliue  soaked  in  boiling  water. 
The  poultices  may  be  advantageously  sprinkled  with  laudanum  or 
belladonna  liniment.  I  say  nothing  of  the  use  of  mercurials,  iodide 
of  potassium,  and  other  so-called  absorbent  remedies,  since  I  believe 
them  to  be  quite  valueless,  and  apt  to  divert  attention  from  more 
useful  plans  of  treatment. 

Importance  of  Rest. — The  most  absolute  rest  in  the  recumbent  posi- 
tion is  essential,  and  it  should  be  persevered  in  for  some  time  after 
the  intensity  of  the  symptoms  is  lessened.  The  beneficial  effect  of 
rest  in  alleviating  pain  is  often  seen  in  neglected  cases,  the  nature  of 
which  has  been  overlooked,  instant  relief  following  the  laying  up  of 
the  patient. 


PELVIC    CELLULITIS    AND    PELVIC    PERITONITIS,  843 

Counter-irritation. — When  the  acute  symptoms  have  lessened  ab- 
sorption of  the  exudation  may  be  favored,  and  considerable  reliet 
obtained,  from  counter-irritation,  which  should  be  gentle  and  long- 
continued.  The  daily  use  of  tincture  of  iodine  until  the  skin  peels, 
perhaps  best  meets  this  indication ;  but  frequently  repeated  blisters 
are  often  very  serviceable.  This  I  believe  to  be  a  better  plan  than 
keeping  up  an  open  sore  with  savine  ointment,  or  similar  irritating 
applications. 

O-peninij  of  Pelvic  Ahscesses. — When  suppuration  is  established  the 
question  of  opening  the  abscess  arises.  When  this  points  in  the 
groin,  and  the  matter  is  superficial,  a  free  incision  may  be  made,  and 
here,  as  in  mammary  abscess,  the  antiseptic  treatment  is  likelv  to 
prove  very  serviceable.  The  abscess  should,  however,  not  be  opened 
t(w  soon,  and  it  is  better  to  wait  until  the  pus  is  near  the  surface. 
The  importance  of  not  being  in  too  great  a  hurry  to  open  pelvic 
abscesses  has  been  insisted  on  by  West,  Duncan,  and  other  Avriters, 
and  I  have  no  doubt  the  rule  is  a  good  one.  It  is  more  especially 
applicable  when  the  abscess  is  pointing  in  the  vagina  or  rectum, 
where  exploratory  incisions  are  apt  lo  be  dangerous,  and  when  the 
presence  of  pus  should  be  positively  ascertained  before  operating. 
We  have  in  the  aspirator  a  most  useful  instrument  in  the  treatment 
of  such  cases,  which  enables  us  to  remove  the  greater  part  of  the  pus 
without  any  risk,  and  the  use  of  which  is  not  attended  with  danger, 
even  if  employed  prematurely.  If  it  do  not  sufl&ciently  evacuate  the 
abscess,  a  free  opening  can  afterwards  be  safely  made  with  the  bis- 
toury. The  surgical  treatment  of  pelvic  abscess  is,  however,  too 
wide  a  subject  to  admit  of  being  satisfactorily  treated  here. 

Diet  and  Reyimen. — The  diet  should  be  abundant,  but  simple  and 
nutritious.  In  the  early  stages  of  the  disease,  milk,  beef-tea,  eggs, 
and  the  like,  will  be  sufficient.  After  suppuration  a  large  quantitv 
of  animal  food  is  required,  and  a  sufficient  amount  of  stimulants'. 
The  drain  on  the  system  is  then  often  very  great,  and  the  amount  of 
nourishment  patients  will  require  and  assimilate,  when  a  copious 
purulent  discharge  is  going  on,  is  often  quite  remarkable.  A  general 
tonic  plan  of  medication  Avill  also  be  required,  and  such  drugs  as 
iron,  quinine,  and  cod-liver  oil,  will  prove  useful. 


r£9FBBTX 

©FTHE  V 

NEW -YORK 


INDEX. 


ABDOMEN,  adipose  enlargement  of,  150, 
[151] 

enlargement    of,   as    a   sign  of  preg- 
nancy, 141 

state  of,  after  delivery,  544 
Abdominal  pregnancy.   (^See  Extra-uterine 

pregnancy.) 
Abortion,  235 

causes  of,  237 

difficulty  in  jjrocuring  artificial,  236 

liability  to  recurrence  of,  23G 

retention  of  secundines  in,  241,  246 

symptoms  of,  241 

treatment  of,  241 

production  of,   in  yomiting  of  preg- 
nancy, 192 

[value  of  opium  in  prevention  of,  242] 
Abscess  of  mammae.     (<S'ee  Mammary  ab- 
scess.) 
Abscess,  pelvic,     (^ee  Pelvic  cellulitis.) 
After-pains,  547 

treatment  of,  548 
Age,  influence  of,  in  labor,  335 
Albuminuria  in  pregnancy,  197 

relation  of,  to  eclampsia,  568 

relation  of,  to  puerperal  insanity,  581 
Allantois,  98 
Amnion,  formation  of,  97 

pathology  of,  229 

structure  of,  100 
Amputations  (intra-uterine),  232 
Anaemia  in  pregnancy,  196 
Anaesthesia  in  labor,  288 

in  forceps  operations,  472 

value  of,  in  difficult  cases  of  turning, 
464 
Anasarca  in  pregnancy,  199 
Ante-version  of  the  gravid  uterus,  208 
Apoplexy  during  or  after  labor,  568,  626 
Arbor  vitae,  51 
Area  germinativa,  96 
Area  pellucida,  97 
Areola,  72 

changes  of,  during  fjregnancy,  139 
Arm,  presentation  of.     {See  Shoulder  pre- 
sentation.) 

dorsal  displacement  of,  326 
Artificial  human  milk,  565 
Artificial  respiration  in  cases  of  apparent 

still-birth,  552 
Ascites  as  a  cause  of  dystocia,  369 


Asphyxia  (idiopathic),  626 
[Atmosphere,    advantages  of  a   pure,   in 

preventing  abortion,  243] 
Auscultatory  signs  of  pregnancy,  145 


BAGS  (Barnes's).     (5'ce  Dilators.) 
Ballottemeut,  143 
Bi-lobed  uterus,  gestation  in,  185 
Binder,  uses  of,  287 

Bladder,  distension  of,  as  a  cause  of  pro- 
tracted labor,  335 
state  of,  after  delivery,  547 
Blastodermic  membrane,  91 

division  and  layers  of,  96 
Blood,  alteration  in,  after  delivery,  541 
Blood-diseases  transmitted  to  foetus,  229 
Blunt-hook  in  breech  presentation,  303 
Bowels,  action  of,  after  delivery,  550 
Breech   jiresentations.      {See  Pelvic  pre- 
sentations.) 
Broad  ligaments  of  uterus,  60 
[Bromide  of  sodium  j)refei-red  to  bromide 

of  potassium,  202] 
Bronchitis  as  a  cause  of  protracted  labor, 

335 
Brow  presentations,  312 


CESAREAN  section,  325,  353,  381,  506 
causes  of  mortality  after,  513 
causes   requiring   the  operation, 

510 
description  of,  517 
history  of,  506 
post-mortem  operation,  511 
results  to  child  in,  507 
statistics  of,  507 
substitutes  for,  521 
[sutures  in,  518] 
[Csesarean  operation  in  America,  522] 
[in  the  United  Kingdom,  508] 
[with  fibroid  tumor,  353] 
[transverse    position    of    foetus, 

325] 
[in  pelvic  exostosis,  381] 
Calculus  of  bladder  obstructing  labor,  356 
Caput  succedaneum,  272 
Carcinoma  in  pregnancy,  215 

obstructing  labor,  349 
Caries  of  teeth  in  pregnancy,  195 


C645) 


646 


INDEX. 


Carunculse  myrtiformes,  44 
[Catheter  introduced  in  dorsal  decubitus, 
43] 
introduction  of,  43 
Caul,  257 

Cellulitis,  pelvic,     (^ee  Pelvic  cellulitis.) 
Cephalotnbe,  494 
Cephalotripsy.     {See  Craniotomy.) 
Cervix  utei-i,  51 

alterations  of,  after  childbirth,  50 
cavity  of,  50 

dilatation  of,  in  labor,  252 
impaction  of,  before  foetal  head, 

280 
incision  of,  for  rigidity,  350 
modification  of,  by  pregnancy,  128 
raucous  membrane  of,  55 
organic  causes  of  rigidity  of,  348 
rigidity  of,    as    a   cause   of   pro- 
tracted labor,  346 
treatment  of  rigidity,  346 
villi  of,  55 
Charlotte,  Princess  of  Wales,  death  of,  344 
Child  (the  new  born).     {See  Infant.) 
Child,  risks  to,  in  forceps  operations,  479 
Childbirth,  mortality  of,  540 
Chloral  in  labor,  289 

in  rigidity  of  cervix,  347 
Chloroform  in  labor,  290 

in  difficult  cases  of  turning,  464 
iu  rigidity  of  cervix,  347 
Chorea  in  pregnancy,  203 
Chorion,  101 

vesicular  degeneration  of,  221 
Circulation  of  foetus,  121 
Cleavage  of  yelk,  90 
Clitoris,  42 
Coccyx,  27,  28 

ligaments  of,  28 
ossification  of,  28 
mobility  of,  28 
Cold  in  the  treatment  of  puerperal  hyper- 
pyrexia, 611 
Colostrum,  554 
Complex  presentations,  325 
Conception,  signs  of,  135 
Constijjation  in  pregnancy,  193 
[Constriction  of  uterus,  tetanoid,  256] 
Continued  fever  in  pregnancy,  213 
Convulsions  (puerperal).      {See   Eclamp- 
sia.) 
Corps  reticule,  99 
Corpus  luteum,  76 
Cranioclast,  494 
Craniotomy,  491 

cases  requiring,  496 
comparative  merits  of,  and  cephalo- 
tripsy, 500 
description  of  cephalotripsy,  501 
extraction  of  head  by  craniotomy  for- 
ceps, 502 
method  of  perforating,  499 
perforators,  492 

perforation  of  after-coming  head,  499 
religious  objections  to,  491 


Craniotomy  forceps,  493 

Crotchets,  493 

Cystocele,  obstructing  labor,  355 


DEATH,    apparent,    of  new-born    child. 
{See  Infant.) 
Death,  sudden,  during  labor  and  the  puer- 
peral state,  626 
from  air  in  the  veins,  627 
functional  causes  of,  627 
organic  causes  of,  626 
Decapitation  of  foetus,  504 
Decidua,  91 

at   end  of  pregnancy,    and   after  de- 
livery, 95 
cavity  between  d.  vera  and  reflexa,  95 
divisions  of,  91 
fatty  degeneration  of,  as  the  cause  of 

labor,  249 
formation  of  d.  reflexa,  93 
structure  of,  92 
Delivery,  state  of  patient  after,  541 
contraction  of  uterus  after,  543 
management  of  patient  after,  547 
nervous  shock  after,  541 
prediction  of  date  of,  155 
signs  of  recent,  158 
state  of  pulse  after,  541 
weight  of  uterus  after,  544 
Diameters  of  foetal  skull,  113 

of  pelvis,  33 
Diarrhoea  in  pregnancy,  193 
[Diet,  milk,  in  nursing  mothers,  558] 
of  lying-in  women,  548 
[wet-nurse,  557] 
Dilators  (caoutchouc)  in  the  induction  of 
premature  labor,  446 
in  rigidity  of  cervix,  348 
Diphtheria  in  the  puerperal  state,  589 
Diseases  of  pregnancy,  188 
albuminuria,  197 
anaemia  and  chlorosis,  196 
carcinoma,  215 
cardiac  diseases,  213 
chorea,  203 
constipation,  193 
diarrhoea,  193 
disorders  of  the  nervous  system, 

201 
respiratory  organs,  195 
teeth,  194 

urinary  system,  204 
displacements  of  the  gravid  ute- 
\  rus,  207 

epilepsy,  214 
eruptive  fevers,  212 
fibroid  tumors,  217 
hemorrhoids,  194 
icterus,  215 
leucorrhoea,  206 
ovarian  tumor,  215 
palpitation,  196 
paralysis,  202 
pneumonia,  213 


INDEX, 


647 


Diseases  of  pregnancy — 
jiruritiis,  206 
ptyalisrn,  194 
syncope,  196 
syphilis,  214 
vai-icose  veins,  207 
vomiting  (excessive),  189 

Dropsies  affecting  the  foetus,  231 

Ductus  arteriosus,  122 
venosus,  122 

Dystocia  from  fcetus,  357 


ECLAMPSIA,  568 
cause  of  death  in,  571 
condition  of  patient  between  the  at- 
tacks, 570 
confusion    from    defective    nomencla- 
ture, 568 
exciting  causes  of,  573 
obstetric  management  in,  576 
pathology  of,  571 
premonitory  symptoms  of,  568 
relation  of,  to  labor,  570 
results  to  mother  and  child  in,  570 
symjjtoms  of,  569 
transfusion  in,  531 
Traube  and   Rosenstein's    theory  of, 

572 
treatment  of,  573 
[venesection  in,  575] 
uriemic  theory  of,  568 
views  of  MacDonald,  573 
Ecraseur,  use  of,  as  a  substitute  for  crani- 
otomy, 496 
Embolism.     (See  Thrombosis.) 
Embryotomy,  503 
Emotion,  mental,  as  a  cause  of  protracted 

labor,  335 
Epiblast,  96 

Epilepsy,  in  pregnancy,  214 
Epileptic  convulsions,  568 
Ergot  of  rye,  338 

as    a  means   of  inducing   labor, 

445 
objections  to  use  of,  338 
mode  of  administration,  338 
value  of,  after  delivery,  287 
Eruptive  fevers  in  pregnancy,  212 
Erysipelas,  as  a  cause  of  puerperal  septi- 
caemia, 595 
Ether  in  labor,  291 

[in  the  United  States,  291] 
Exhaustion,  importance  of  distinguishing 
between    temporary   and   permanent  in 
labor,  337 
Expression,  uterine,     (^ee  Pressure.) 

of  the  placenta,  286 
Extra-uterine  pregnancy,  166 

abdominal  variety  of,  177 
causes  of,  168 

changes  of  the  foetus  in,  179 
classification  of,  167 
diagnosis  of  abdominal  variety, 
ISO 


Extra-uterine  pregnancy — 

diagnosis  of  tubal  variety,  172 
gastrotomy  in,  [174],  175,  181 
pseudo-labor  in,  178 
[vaginal  section  in,  174] 
symptoms  of  ruj^ture  in,  171 
treatment  after  rupture,  [177] 
treatment  of  abdominal  variety, 

181 
tubal  variety,  169 
treatment  of  tuljal  variety,  173 

Evisceration,  504 


FACE  presentation,  303 
causes  of,  304 
diagnosis  of,  305 
difficulties  connected  with,  311 
erroneous  views  formerly  enter- 
tained of,  304 
mechanism  of  delivery  in,  305 
mento-posterior  positions  in,  310 
prognosis  in,  310 
treatment  of,  310 
Fallopian  tubes,  63 
False  pains,  character  and  treatment  of, 

276 
Faradization  in  apparent  still-birth,  552 
Fibroid  tumor  in  pregnancy,  217 

obstructing  labor,  352 
Fillet,  489 

in  breech  presentations,  303 
nature  of  the  instrument,  490 
objections  to  its  use,  491 
Foetal  head,  anatomy  of,  112 

induction  of  i^remature  labor,  for 
large  size  of.'  442 
Foetal    heart,    sounds    of,    in   presjuancv, 

145 
Foetus,  anatomy  and  physiology  of,  109 
[anencephalous,    causing    eneuresis, 

205] 
appearance  of  a  putrid,  234 
appearance  of,  at  various  stages  of  de- 
velopment, 110 
at  term.  111 

[cleaning  of,  without  water,  553] 
circulation  of,  121 
changes  in  circulation  of,  as  cause  of 

labor,  248 
changes  in  position  of,  during  preg- 
nancy, 115 
death  of,  234 

detection  of  position  in  utero  by  pal- 
pation, 115 
early  viability  of,  235 
excessive  development  of,  as  a  cause 

of  difficult  labor,  370 
explanation  of  its  position  in  utero, 

117 
functions  of,  119 
nutrition  of,  119 
pathology  of,  228 
position  of,  in  utero,  115 
respiration  of,  120 


648 


INDEX. 


Foetus — 

signs  and  diagnosis  of  death  of,  234, 

500 
[gigantic,  111] 
Fontanelles,  112 
Foot,  diagnosis  of,  295 
Foot  presentations.     {See  Pelvic  presenta- 
tions.) 
Foramen  ovale,  122 
Forceps,  465 

action  of,  469 

advantages  of  pelvic  curve  in,  466 

[application  at  inferior  strait,  487] 

[at  superior  strait,  487] 
application  of,  to  after-coming  head  in 

breech  presentations,  301 
application  of,  within  the  cervix,  351 
[carried  over  abdomen,   to  complete 

delivery  of  head,  488] 
cases  in  which  a  straight  instrument 

should  be  used,  466 
dangers  of,  342,  478 
dangers  of,  to  child,  479 
description  of,  465 
description  of  the  operation,  472 
difference  between  high  and  low  ope- 
rations, 471 
disadvantages  of  a  weak  instrument, 

468 
frequent  use  of,  in  modern  practice, 

340,  465 
high  operations,  477 
[in  America,  479] 
long,  467 
preliminary      considerations      before 

using,  471 
short,  466 
use  of  anaesthetics  in  forceps  delivery, 

472 
use  of  in  deformed  pelvis,  387 
use   of  in    difficult   occipito-posterior 

positions,  314 
use  of  in  protracted  labor,  340 
[Forceps,  Bedford's,  483] 
[Clemann's,  469] 
[Davis's,  482] 
[Elliot's,  483] 
[Hodge's,  481] 
[Meigs's  craniotomy,  503] 
[Sawyer's,  484] 
[Wallace's,  482] 
[White's,  483] 
Forceps-saw,  495 
Fossa  navicularis,  44 
Funis.     {See  Umbilical  cord.) 


GALACTAGOGUES,  558 
Galactorrhooa,  560 
Galvanism  as  a  means  of  indiacing  labor, 

445 
Gangrene  of  limbs  from  arterial  obstrtic- 

tion,  613 
Gastrotomy,  after  rupture  of  uterus,  432 
in  extra-uterine  pregnancy,  174,  183 


Gastro-elytrotomy.      {See  Laparo-elytrot- 

omy.) 
Generative  organs,  in  the  female,  41 

division  according  to  function,  41 
Germinal  vesicle,  disappearance  of,  after 

impregnation,  89 
Gestation.     {See  Pregnancy.) 
Graafian  follicle,  67 

structure  of,  69 


H HEMATOCELE,  obstructing  labor,  356 
Haemorrhoids,  in  pregnancy,  194 
[Hand,  introduction  of,  in  occipito-poste 

rior  positions,  315] 
Hand-feeding  of  infants,  564  ^ 

ass's  milk  in,  564 
artificial  human  milk  in,  565 
causes  of  mortality  in,  564 
cow's  milk  in,  and  its  prepara- 
tion, 564 
goat's  milk  in,  564 
method  of,  566 
Head  presentations,  261 

description   of    cranial    positions 

in,  262 
division  of,  262 
explanation  of  frequency  of  1st 

position,  263 
frequency  of,  263 
mechanism  of  1st  position,  265 
2d  position,  270 
3d  position,  270 
4th  position,  272 
relative  frequency  of  various  po- 
sitions, 263 
Heart,  diseases  of,  in  jiregnancy,  213 

hypertrophy  of,  in  pregnancy,  132 
Hemorrhage,  accidental,. 405 

causes  and  pathology  of,  406 

concealed  internal,  407 

diagnosis,    prognosis,    and    treatment 

of  concealed  internal,  406 
prognosis  of,  407 
symj^toms  and  diagnosis  of,  406 
treatment  of,  408 
Hemorrhage  after  delivery,  409 
causes  of,  409 
constitutional   predisposition   to, 

413 
curative  treatment  of,  415 
from  laceration  of  maternal  struc- 
tures, 421 
nature's  mode  of  preventing,  259, 

409 
preventive  treatment  of,  414 
secondary  causes  of,  411 
secondary  treatment  of,  421 
symptoms  of,  413 
transfusion  of  blood  in,  422 
Hemorrhage  after  delivery(secondary),  422 
distinction  between,  and  pro- 
fuse lochial  discharge,  422 
local  causes  of,  423 
treatment  of,  424 


INDEX, 


649 


Hemorrliagc,  unavoidable.     {See  Placenta 
pr£3via.) 

Hernia,  in  labor,  35(5 

Hour-glass    contraction    of    uterus,    411, 
[412] 

Hydatids  of  uterus,  221 

Hydramnios,  228 

Hydrocephalus  of  foetus,  as  a  cause  of  dif- 
ficult labor,  3G7 

Hydrorrhoea  gravidarum,  221 

Hymen,  43 

[an  obstacle  to  delivery,  44] 

Hypoblast,  9(3 

Hysteria  during  labor,  568 


FDUCTION  of  premature   labor.     (,5ee 
Premature  labor. ) 
Inertia  of  tlic  uterus,  frequent  child-bear- 
ing as  a  cause  of,  334 
Infant,  apparent  death  of,  551 

appearance  of,  in  cases  of  apparent 

death,  551 
clothing  of,  553 
evils  of  over-suckling,  554 
management  of,  556 
managemeiit  of,  when  food  disagrees, 

567 
treatment  of  apparent  death  of,  551 
various  kinds  of  food  of,  567 
washing  and  dressing  of,  553 
Infantile   mortality,  diminution   of,  as    a 
reason  for  more  frequent  use  of  forceps, 
342 
Inilammatoiy  diseases  affecting  the  foetus, 

231 
Insanity  (puerperal),  577 

classification  of,  577 
of  lactation,  583 
of  pregnancy,  578 
predisposing  causes  of,  578 
puerperal  (proper)  580 
caiises  of,  581 
form  of,  579 
prognosis  of,  583 
post-mortem  signs  of,  583 
symptoms  of,  584 
transient  mania  during  deliverv, 

580 
treatment  of,  58.5- 
treatment  during  convalescence, 

588 
question  of  removal  to  an  asylum, 
588 
Insomnia  in  pregnancy,  202 
Intermittent  fever  affecting  the  fa3tus,  230 
Intestines,    disorders    of,    as    influencing 

labor,  336 
Inversion  of  uterus.     {See  Uterus.) 
Irregular  uterine  contractions  after  labor, 
411 
as  a  cause  of  lingering  labor, 
336 
Irritable  bladder  in  pregnancy,  204 
Ischium,  planes  of  the,  38. 
42 


[AUNDICE  in  pregnancy,  215 


KIESTEIN,  132,  [135] 
Knots  on  the  umlnlical  cord,  227 
Knee  presentation,  295 
Kyphotic  deformity  of  pelvis,  379 


T  ABIA  majora,  41 
1j     Labia  minora,  42 
Labor,  248 

age,  influence  of,  on  335 

anaesthesia  in,  288 

arrest  of,  158 

causes  of,  248 

causes  of  precipitate,  336 

causes  of  i^rotracted,  333 

character  and  source  of  pain  in,  254 

character  of  false  pains,  276 

dilatation  of  cervix  in,  252 

duration  of,  260 

efl'ect  of  uterine  contractions  in,  251 

evil  effects  of  protracted,  332 

induction  of.    (^ee  Premature  labor.) 

influence  of  stage  of,  in  protracted, 

332 
management  of   in  deformed  pelvis, 

387 
management  of  natural,  274 
management  of  third  stage  of,  284 
mechanism  of,  in  head  presentation, 

261 
obstructed  by  faulty  condition  of  the 

soft  parts,  341 
period  of  day   at  which   labor   com- 
mences, 261 
phenomena  of,  248 
position  of  patient  during,  278 
preparatory  treatment,  274 
precipitate,  346 
prolonged  and  precijiitate,  332 
rupture  of  membranes  in,  252 
stages  of,  255 

symptoms  of  protracted,  333 
treatment  of  protracted,  346 
Lactation,  defective  secretion  of  milk  in, 

558 
diet  of  nursing  women  during,  556 
excessive  flow  of  milk  in,  559 
importance  of  to  mother,  554 
importance  of  wet-nursing  to   child, 

554 
insanity  of,  583 
management  of,  555 
means  of  arresting  secretion  of  milk 

in,  557 
period  of  weaning  in,  557 
Laminge  clorsales,  97 
Laj^aro-elytrotomy,  525 
[Laparotomy,  American  i^uerperal,  432] 
Lead-poisoning,  affecting  the  foetus,  230 

as  a  cause  of  abortion,  240 
Leucorrhoea,  in  pregnancy,  205 
Lever.     {See  Vectis.) 


650 


INDEX. 


[Line,  dark  abdominal,  in  negro,  141] 
Liquor  amnii,  100 

uses  of,  101 
source  of,  101 
deficiency  of,  229 
Lochia,  546 

variation  in  amoimt  and  duration  of, 

54(j 
occasional  fetor  of,  546 
Lying-in  hospitals,  mortality  in,  589 
Lypotliemia,  196 


IIIALPRESENTATIONS,  peculiar  form  of 
1*1     bag  of  membranes  in,  294 
Mammary  abscess,  560 

antiseptic  treatment  of,  561 
signs  and  symptoms  of,  560 
treatment  of,  561 
changes  during  pregnancy,  139 
their  diagnostic  value,  140 
glands,  71 

their  sympathetic  relations  with 
the  uterus,  72 
[McKnight's  operation,  175] 
Measles,  affecting  the  foetus,  230 

in  pregnancy,  212 
Meconium,  124 
Membranes,  artificial  rupture  of,  279 

puncture  of,   as  a  means  of  inducing 
labor,  444 
Menstruation,  73 
cessation  of,  84 

during  pregnancy,  136 
changes  in  Graafian  follicle  after,  73 
[increased  by  change  of  residence  to 

a  hot  climate,  79] 
period  of,  duration,  and  recurrence, 

79 
purpose  of,  84 
sources  of  blood  in,  81 
theory  of,  82 

quantity  of  blood  lost  in,  79 
vicarious,  84 
Mesoblast,  96 

[Milk,   Alderney,   too  rich  for   young  in- 
fants, 565] 
artificial  human,  565 
ass's,  564 

cow's,  and  its  preparation,  564 
defective  secretion  of,  558 
excessive  secretion  of,  559 
goat's,  564 
[in  cities,  564] 
means  of  arresting  the  secretion  of, 

557 
secretion  of,  after  delivery,  554 
Milk-fever,  543 
Miscarriage.  (*S'ee  Abortion.) 
Missed  labor,  185,  [186] 
Moles,  237 

Monstrosity  (double),  363 
classification  of,  364 
mechanism  of  delivery  in,  364 
Mons  veneris,  41 


Montgomery's  cups,  93 
Morning  sickness,  137 
Mortality  of  childbirth,  540 
Mucous  membrane  of  uterus. 

rus.) 
[Muller  operation,  521] 


{See  Ute- 


NERVOUS  shock  after  delivery,  542 
Nervous  system,  changes  in  during 
pregnancy,  134 
disorders  of,  in  pregnancy,  201 
excitability  of,  in  puerperal  wo- 
men, 573 
Neuralgia  in  pregnancy,  202 
Nipple,  72 

Nipples,  depressed,  59 
[eczema  from,  559] 
fissures  and  excoriations  of,  559 
Nursing.     {See  Lactation.) 
Nutrition  of  foetus,  119 
Nymphse.     {See  Labia  minora.) 


OBLIQUELY  contracted  pelvis,  378 
Obstetric  bag,  275 
Occipito-posterior  positions,  difiicult  cases 
of,  313 
causes  of    face-to- pubis   delivery 

in,  313 
forceps  in,  315 
treatment  of,  314 
vectis  or  fillet  in,  314 
Omphalo-mesenteric  artery  and  vein,  98 
Opiates,  use  of,  after  delivery,  548 
Os  innominatum,  25 
Osteomalacia,  as  a  cause  of  deformity,  372 

[not  an  American  disease,  373] 
Osteophytes,   formation   of,   during   preg- 
nancy, 134 
Os  uteri,  dilatation  of,  as  a  means  of  in- 
ducing labor,  446 
occlusion  of,  in  labor,  349 
Ovarian   pregnancy.     {See  Extra-uterine 
pregnancy.) 
tumor  in  jiregnancy,  215 
Ovariotomy  in  pregnancy,  216 
Ovary,  64 

functions  of,  73 
structure  of,  64 
vascular  arrangements  of,  68 
Ovule,  69 

changes  in,  after  imj^regnation,  89 
changes  in,  when    retained  in  utero 

after  its  deatli,  238 
formation  of,  67. 
Ovum,  blighted,  retained  in  utero,  247 
Oxytocic  remedies,  338 


PAINS,  after,  547 
false,  256 
irregular  and  spasmodic  as  a  cause  of 

protracted  labor,  336 
labor,  251 


INDEX, 


G51 


Palpitation  in  pregnancy,  196  j 

rauipiiiitonu  plexus,  fjlj 
Paralysis  in  pregnancy,  202 

from  embolism  of  the  cerebral  arte- 
ries, 019 
from  embolism  of  the  main  arteries  of 
the  limb,  G19 
Parovarium,  GO 
Parturient  canal,  axis  of,  37 
J'athology  of  decidua  and  ovnm,  218 
Pelvis,    alterations    in,    articulations    of, 
during  pregnancy,  31 
anatomy  of,  25 
articulations  of,  28 
axes  of,  37 
Csesarean    section    in   deformities    of, 

391 
causes  of  deformity  of,  371 
comparative  estimate  of  turning  and 

forceps  in  deformity  of,  390 
craniotomy  in  deformity  of,  391 
diagnosis  of  deformity,  384 
deformities  of,  371 
development  of,  39,  40 
diflerence  according  to  race,  40 
difference  in  the  two  sexes,  32 
division  into  true  and  false,  32 
equally  contracted,  374 
equally  enlarged,  374 
forceps  in  deformity  of,  388 
induction  of  premature  labor  in  de- 
formity of,  391 
infantile,  39 
kyphotic,  380 
ligaments  of,  28 
masculine,  374 
mechanism  of  delivery  in  deformed, 

383 
movements  of  the  articulations  of,  30 
obliquely  contracted,  379 
planes  of,  37 
Robert's,  380 

soft  parts  connected  witli,  40 
tumors  of,  381 
turning  in  deformity  of,  389 
undeveloped,  375 
Pelvic  cellulitis  and  peritonitis,  636 
etiology  of,  637 
importance  of  distinguishing 
the  two  forms  of  disease, 
636 
connection  with  septicaemia, 

637 
opening  of  abscess  in,  642 
prognosis  of,  642 
relative  frequency  of  the  two 

forms  of  disease,  639 
results  of  physical  examina- 
tion, 640 
seat  of  inflammation  in  cellu- 
litis, 637 
seat  of  inflammation  in  peri- 
tonitis, 638 
suppuration  in,  641 
symptomatology,  639 


Pelvic  cellulitis  and  peritonitis — 
terminations  of,  640 
treatment  of,  641 
two  distinct  forms  of  disease, 
636 
presentations,  292 

application  of  forceps  to  the  after- 
coming  head  in,  301 
causes  of,  292 
danger  to  children  in,  300 
diagnosis  of,  293 
frequency  of,  292 
management  of  impacted  breech 

in,  302 
mechanism  of,  295 
prognosis  in,  293 
treatment  of,  369 
Pelvimeters,  various  forms  of,  385 
Perchloride  of  iron,  injections  of,  in  post- 
partum hemorrhage,  421 
Perforators,  491 

Perineum,  distension  of,  in  labor,  258,  281 
incision  of,  282 
laceration  of,  283 
relaxation  of,  281 

rigidity  of,  as  a  cause  of  protracted 

labor,  351 

Peritonitis,  pelvic.    (See  Pelvic  cellulitis.) 

Peritonitis,  puerperal.    (See  Septicemia.) 

Phlegmasia     dolens.       (.See    Thrombosis, 

peripheral  venous.) 
Placenta,  102 

adhesion  of,  after  delivery,  413 

degeneration  of,  108 

detachment  of,  in  labor,  259 

expression  of,  286 

foetal  portion  of,  103 

form  of,  in  man  and  animals,  102 

functions  of,  108 

maternal  portion  of,  106 

minute  structures  of,  103 

pathology  of,  224 

[long-retained,  418] 

sinus  system  of,  105 

sounds  produced  during  separation  of, 

149 
treatment  of  adherent,  417 
Placenta  membranacea,  224 
Placenta  praevia  393,  [394,  402] 
causes  of,  394 

causes  of  hemorrhage  in,  397 
natural  termination  of  labor  in, 

399 
pathological  changes  of  placenta 

in  398 
prognosis  in,  394 
sources  of  hemorrhage  in,  396 
summary  of   rules  of   treatment 

in,  404 
symptoms  of,  395 
treatment  of,  400 
turning  in,  462 
Placenta  succenturia,  224 
Placentitis,  225 
Plugging  of  vagina,  245 


652 


INDEX. 


Plural  births,  160,  359 

arrangement    of    placentae     and 

membranes  in,  162 
causes  of,  162 
diagnosis  of,  163 
relative  frequency  of,  in  different 

countries,  160 
sex  of  children  in,  161 
treatment  of,  360 
Pneumonia  in  pregnancy,  213 
"Polar  globule,"  89 
[Polypus,  an  obstacle  to  delivery,  355] 
Porro  operation,  520 
Position  of  cranium  in  head-presentation. 

(5'ee  Head  j^resentation.) 
Post-par  turn   hemorrhage.      (/See   Hemor- 
rhage.) 
Pregnancy,  125 

abnormal,  160 

affections  of  respiratory  organs,  194, 

[195] 
alteration  of  color  of  vaginal  mucous 

membrane  as  a  sign  of,  144 
ballottement  as  a  sign  of,  143 
changes  in  the  bloocl  during,  132 
changes  in  the  liver,  lymphatics,  and 
spleen  dui-ing,  133 
in  tlie  urine  during,  134 
[complicated    ■with    ovarian    tumor, 

216J 
dejjosits  of  pigmentary  matter  during, 

141 
differential  diagnosis  of,  150 
dress  of  patient  in,  274 
duration  of,  154 
enlargement  of  abdomen  as  a  sign  of, 

141 
extra-uterine.       {See     Extra-uterine 

pregnancy.) 
foetal  movements  in,  141 
formation  of  osteophytes  during,  133 
hypertrophy   of    the    heart    during, 

133 
in  cases  of  double  uteriis,  57 
in  the  absence  of  menstruation,  137 
intermittent  uterine  contractions  as  a 

sign  of,  142 
ptyalism  in,  194 
prolapse  of  the  uterus  in,  207 
protraction,  156 
pruritis  in,  206 
quickening,  142 
sickness  of,  137 
signs  and  diagnosis  of,  136 
sounds  produced  by  the  foetal  move- 
ments in,  149 
spurious,  153 

sympathetic  disturbances  of,  137 
uterine  fluctuation  in,  144 
vaginal  signs  of,  143 
pulsation  in,  144 
Premature  labor,  230 

history  of  the  operation  of  induc- 
tion of,  442 
induction  of,  442 


Premature  labor — 

in  deformed  pelvis,  393 
injection  of  carbonic  acid  gas  as  a 

means  of  inducing,  448 
insertion  of  flexible  bougie  as  a 

means  of  inducing,  448 
objects  of  the  ojperation  of  induc- 
tion of,  442 
oxytocics  as  a  means  of  inducing, 

445 
period  for  the  induction  of,  in  de- 
formed pelvis,  393 
precautions  as  regards  the  child 

in  the  induction  of,  449 
puncture  of  the  membranes  as  a 

means  of  inducing,  445 
separation  of  the  membranes  as  a 

means  of  inducing,  447 
vaginal  and  uterine  douches  as  a 
means  of  inducing,  447 
Pressure  as  a  means  of  inducing  uterine 
contractions,  339 
mode  of  applying,  340 
Prolapse  of  umbilical  cord.     {See  Umbili- 
cal cord.) 
Ptyalisms  in  pregnancy,  194 
Puerperal  convulsions.     {See  Eclampsia.) 
fever.     {See  Septicasmia.) 
mania.     {See  Insanity.) 
state,  540 

after-treatment  in  [549],  550 
diet  and  regimen  in,  548 
diminution  of  uterus  in,  543 
imj)ortance  of  prolonged  rest  in, 

550 
secretions  and  excretions  in,  542 
temperature  in,  542 
Pulmonaiy  arteries,   anatomical   arrange- 
ment of,  as  favoring  thrombosis,  616 
Pulse,  state  of,  after  delivery,  541 


QUICKENma,  142 
[Quinine  as  an  oxytocic,  338] 


RACE  as  influencing  the  size  of  the  foetal 
skull,  114 
Recto-vaginal  fistula,  434 
Respiration  of  fostus,  120 
Retroversion  of  the  gravid  uterus,  208 
Rickets  as  a  cause  of  pelvic  deformity,  373 
Rosenmiiller,  organ  of.    ( See  Parovarium.) 
Round  ligaments  of  the  uterus,  61 
Rupture  of  uterus.     {See  Uterus.) 


SACRUM,  anatomy  of,  27 
mechanical  relations  of,  27 
Salivation  in  pregnancy,  194 
Scarlet  fever  aflfecting  the  foetus,  230 
in  pregnancy,  212 
in  the  puerperal  state,  596 
Scybalae  in  the  rectum  obstructing  labor, 
356 


INDEX, 


663 


Scpticjiemia  (puerperal),  589 
bacteria  in,  (JOi 
cliannels  of  diU'usion  in,  GOl 

through  which  septic  matter  may 
be  absorbed,  593 
cold  in  treatment  of,  (ill 
conduct  of  i^ractitioner  in  regard  to, 

599 
contagion  from   other   puerperal  pa- 
tients as  a  cause  of,  598  • 
description  of,  605 
division  into  aato-genetic  and  hetero- 

genetic  forms,  594 
epidemics  of,  590 
history  of,  589 
importance  of  antiseptic  precautions 

in,  600 
influence   of    cadaveric    poison   as    a 

cause  of,  595 
inflaence  of  zymotic  disease  in  caus- 
ing, 595 
its  connection  with   pelvic   cellulitis 

and  peritonitis,  637 
local  changes  in,  601 
mode  in  which  the  poison  may  be  con- 
veyed to  patients  in,  599 
nature  of  sex^tic  poison,  601 
pathological  phenomena  in,  603 
prevention  of,  600 
pyfemic  forms  of,  604 
sources  of  auto-infection  in  594 

of  hetero-infection,  594,  [599] 
symjDtoms  of  tlie  intense  forms,  605 
theory  of  an  essential  zymotic  fever, 
591 
of  identity  with    surgical  septi- 

cfemia,  591 
of  local  origin,  590 
transfusion  of  blood  in,  530 
treatment  of  a,  607 
[venesection  in,  609] 
Warburg's  tincture  in  the  treatment 
of,  611 
Sex,  discovery  of,  of  fa^tus  during  preg- 
nancy, 146 
of  foetus  as  influencing  the  size  of  the 
skull,  114 
Shoulder  presentations,  317 
diagnosis  of,  320 
division  of,  317 
mechanism  of,  322 
prognosis  and  frequency  of,  319 
spontaneous  version  in,  322 
treatment  of,  329 
[Siamese  twins,  how  born,  364] 
Sickness  of  pregnancy,  137 
[Silver  uterine  sutures,  519] 
[Sleep  on  inclined  plane,  for  relief  of  dys- 
pnoea of  pregnancy,  195] 
Smallpox  affecting  the  foetus,  229 

in  pregnancy,  212 
Smith's,  Tyler,  theory  of  labor,  250 
Spondylolithesis,  377 
Spontaneous  evolution,  322 
version,  320 


Spurious  pregnancy,  153 
diagnosis  of,  153 
symptoms  of,  153 
[Story  of    the    Princess  of    Swarzenberg, 

512] 
Symphyseotomy,  520 
Syncope  during  or  after  labor,  620 

in  pregnancy,  196 
Syphilis  affecting  the  foetus,  230 
as  a  cause  of  abortion,  239 
in  pregnancy  214 
[Stethoscojje,  Cammann's,  147] 
Sui)er-fecundation  and  super-fa'tation,  164 
Sutures  of  foetal  head,  112 


TEMPERATURE  after  delivery,  542 
Thrombosis  (periplieral  venous),  629 
changes  in  thrombi  in,  637 
condition  of  the  affected  limb, 

629 
detachment  of  emboli  in,  634 
history  and  pathology  of,  630 
progress  of  the  disease,  630 
symptoms  of,  629 
treatment  of,  633 
(puerperal),  613 

arterial  thrombosis  and  embo- 
lism, 624 
cardiac  murmur  in  pulmonary 

622 
cases  illustrating  recovery  from 

pulmonarj^,  620 
causes  of  death  in  pulmonary, 

622 
clinical  facts  in  favor  of  pul- 
monary, 616 
conditions  which  favor  throm- 
bosis in  the  puerperal  state, 
614 
distinction  between  thrombosis 

and  embolism,  615 
phlegmasia     dolens     a    conse- 
quence of,  614 
post-mortem  apiaearance  of  clots 

in  pulmonary,  622 
question  of  primary  thrombosis 
in   the   pulmonary  arteries, 
630 
question  of  recovery  from  pul- 
monary, 615 
symptoms  of  arterial,  624 

of  pulmonary  obstruction 
in,  618 
treatment  of  arterial,  626 
of  pulmonary,  623 
Thrombus.     {See  Hsematocele.) 
Toothache  in  pregnancy,  194 
Transfusion  of  blood,  530 

addition  of  chemical  reagents  to 
prevent  coagulation  of  fibrine, 
534 
cases  suitable  for  the  operation, 

536 
dangers  of  the  operation,  536 


854 


INDEX. 


Transfusion  of  blood — 

defibrination    of    blood    in,   534, 

[534] 
diliiculties  of  the  operation,  532 
efl'ects  of  successful  transfusion, 

539 
history   of    the    operation,    530, 
immediate  transfusion,  533 
method  of  injecting  defibrinated 

blood,  539 
method  of  perfoi'ming  immediate 

transfusion,  537 
method  of  preparing  defibrinated 

blood,  538 
nature  and  object  of  the  opera- 
tion, 531 
secondary  effects  of,  539 
statistical  results  of,  536 
Tropics,  influence  of  residence  in,  on  labor, 

334 
Trunk,  presentation   of.      (^ee    Shoulder 

presentations.) 
Tumors,  diagnosis  of  iiterine  and  ovarian, 
157 
foetal,  232 

obstructing  labor,  370 
Tunica  albuginea,  G6 
Turning,  449 

anjesthesia  in,  455 
by  combined  method,  453 
by  external  manipulation  only,  451 
cases  suital)le  for  the  operation,  451 
for   operating   by    combined 
method,  452 
cephalic,  453 

choice  of  hand  to  be  used,  455 
history  of  the  operation,  449 
in  abdomino-anterior  positions,  463 
in  deformed  pelvis,  359 
in  placenta  prsevia,  402,  462 
method  of  cephalic  450 

of  performing  by  external  manip- 
ulation, 451 
of  podalic,  454 
object  and    nature  of  the  operation, 

450 
period  when  the  operation  should  be 

performed,  455 
podalic,  454,  459 
position  of  patient  in,  454 
statistics  and  dangers  of,  451 
value  of  ansestheticis  in  difficult  cases 
of,  464 
Twins.     {See  Plural  births.) 
[Carolina,  how  born,  366] 
conjoined,  361 
locked,  360 


UMBILICAL  cord,  108 
knots  of,  109,  237 
ligature  of,  283 
pathology  of,  227 
prolapse  of,  326 
causes  of,  328 


Umbilical  cord,  prolapse  of — 
diagnosis  of,  328 
frequency  of,  327 
postural  treatment  of,  328 
prognosis  of,  329 
reposition  of,  330 
Umbilical  souffle,  147 

vesicle,  97 
Urachus,  99 

UTsemia,  in  connection  with  eclampsia,  540 
in  connection  with  puerperal  insanity, 
581 
Urethra,  43 
Urine,  changes  in,  during  pregnancy,  134 

retention  of,  after  delivery,  548 
Uterine  fluctuation,  as    a   sign    of    preg- 
nancy, 144 
souffle,  147 
Utero-sacral  ligaments,  62 
Uterus,  47 

analogy  of  interior  of,  after  delivery, 
and  stump  of  an  amputated  limb, 
95 
anomalies  of,  57 
ante-partum   hour-glass    contraction, 

351,  [351] 
arrangement  of  muscular  fibres  of,  52 
axis  of,  during  pregnancy,  127 
changes  in  cervix  during  pregnancy, 

127,  143 
changes  in  form  and  dimensions  of, 

during  pregnancy,  125 
changes    in   mucous    membranes    of, 

after  delivery,  545 
changes    in  mucous    membranes    of, 

after  impregnation,  91 
changes    in   tissues  of,   during  preg- 
nancy, 130 
changes   in  the  vessels  of,  after   de- 
livery, 544 
congestive  hypertrophy  of,  151 
contractions  of,  in  labor,  251 
dimensions  of,  49 
diminution  in  size  of,  after  delivery, 

544 
distension  of,  as  a  cause  of  labor,  249 
distension  of,  by  retained  menses,  151 
fatty  transformation  of,  after  delivery, 

527 
[hour-glass  contraction,  412] 
intermittent   contractions    of,  during 

pregnancy,  142,  [143] 
internal  surface  of,  50 
inversion  of,  435 

differential  diagnosis  of,  437 

production  of,  437 

results  of  physical  examination 

in,  437 
synjptoms  of,  436 
[spontaneous  reposition,  440] 
treatment  of,  439 
ligaments  of,  60 
lymphatics  of,  57 

malposition  of,  as  a  cause  of  protracted 
labor,  336 


INDEX, 


655 


uterus — 

mode  of  action  in  labor,  251 

mucous  membrane  of,  53 

muscular  fibres  of,  52 

nerves  of,  57 

[partitioned,  59] 

[persistent    intermittent    contraction 

of,  1413] 
regional  division  of,  50 
relations  of,  48  * 

retroversion  of  gravid,  210 
rupture  of,  42G 

alterations  of  tissues  in,  427 

causes  of,  427 

comparative    result    of    various 
methods  of  treatment  in,  432 

prognosis  of,  430 

seat  of  laceration  in,  427 

symi^toms  of,  430 

treatment  of,  430,  434 
[gastrotomy  in,  433] 
size   of,  at   various   periods  of  preg- 
nancy, 126 
state  of,  in  protracted  labor,  334 
structures  composing,  51 
utricular  glands  of,  53 
vessels  of,  56 
weiglit  of,  after  delivery,  544 


VAGINA,  45 
bands  and    cicatrices  of,  obstructinc 

delivery,  350 
contraction  of,  after  delivery,  543 
lacerations  of,  433 


Vagina — 

orifice  of,  43 

structure  of,  46 
Varicose  veins  in  pregnancy,  207 
Vectis,  489 

action  of,  489 

cases  in  which  it  is  applicable,  490 
Veins,  entrance  of  air  into,  as  a  cause  of 

sudden  deatli  after  delivery,  627 
Venesection  for  rigidity  of  cervix,  347 
Version.     (6'ec  Turning.) 

[by  the  vertex,  314] 
Vesico-uterin(!  ligaments,  61 
Vesico-vaginal  fistula,  433 
Vestibule,  42 

Vicarious  menstruation,  84 
Vomiting  in  pregnancy,  189 
Vulva,  41 

condition  of,  after  delivery,  545 

oedema  of,  obstructing  labor,  356 

vascular  su])ply  of,  45 
Vulvo-vaginal  glands,  44 


WARBURG'S  tincture,  611 
Weaning.      (5^c  Lactation.) 
Wet-nurse,  selection  of,  555 
WoMan  bodies,  58,  110 
Wounds  of  the  foetus,  232 


ZONA  pellucida,  69 
Zymotic  disease,  affecting  the  fatus, 

229 
as  a  cause  of  septicaemia,  595 


HENRY  O.  LEA'S  SON  &  CO.'S 

(I/ATE  HENRT  C.  LEA) 

OI_..A.SSIir«x:KIID     O..A^T..^I_iOOXJ:m 

OF 

MEDICAL  AND  SUEGICAL  PUBLICATIONS. 

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Nos.  706  and  708  Sansom  St.,  Philadelphia,  March,  1881. 


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THE  AMERICAN  JOURNAL  OF  THE  MEDICAL  SCIENCES, 

Edited  by  I.  MINIS  HAYS,  M.D., 
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with  him.  We  quite  agree  with  the  critic,  that  this  i  JouiTjal  ol  the  Medical  Sciences,  a  periodical  of 
journal  issecond  to  none  in  the  language, and  cheer- '  W'wid- wide  reputation;  the  ablest  and  one  of  the 
fully  accord  to  it  the  first  place,  for  nowhere  shall  oldei't  periodicals  in  the  world — a  journal  which  has 
■we  find  more  able  and  more  impartial  criticism,  and  :  an  unsnlVied  record. — Gross's  History  of  American 


nowhere  such  a  repertory  of  able  original  articles 
Indeed,  now  that  the  "British  and  Foreign  Mcdico- 
Chiruigical  Review"  has  terminated  its  career,  the 
American  Journal  stands  without  a  rival. — London 
3Jf,d.  Tivies  and  Gazette,  Nov.  24,  1877. 

The  best  medical  journal  on  the  continent. — Bos- 
ton Med.  olid  Surg.  Journal,  April,  1879. 

The  present  number  of  the  American  Journal  is 
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of  aiaiutaining  the  well-earned  reputation  of  the 
review.  Our  venerable  contemporary  has  pur  best 
vfisV'S,  and  we  can  only  express  the  hope  that  it 
may  coatinue  its  work  with  as  much  vigor  and  ex- 
ceU«3ioe  lor  the  next  fitty  years  as  it  has  exhibited 
in  th«  past. — London  Lancet,  Nov.  24,  1877. 


Med.  Liieruturf.   1876. 

The  best  merfical  j  ournal  ever  published  in  Europe 
or  America. — Va,.  Med:  Monthly,  May,  1679. 

It  is  universally  acknowledged  to  be  the  leading 
American  medical  journal,  and,  in  our  opinion,  is 
second  to  none  in  the  language. — Boston  Med.  and 
Surg.  Journal,  Oct.  1877. 

This  is  the  medical  journal  of  our  country  to  which 
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it  has  been  the  medium  through  which  our  ablest 
writers  have  made  known  their  discoveries  aud 
observations.— ^arfr«*.5  of  L.  P.  Tande.ll,  M.l).,  he- 
fore  International  Med.  Congress,  Sept.  1876. 


And  that  it  was  specifically  included  in  the  award  of  a  medal  of  merit  to  the  Pub-  . 
Ushers  in  the  Vienna  Exhibition  in  1873. 

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Henry  C.  Lea's  Son  &  Co.'s  Publications — (Am.  Journ.  Med.  Set'.).    3 

current  information  which  could  not  be  accommodated  in  tlie  Quarterly.  It  consisted 
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complete  sets  for  the  year  1881. 

Ig^  The  safest  mode  of  remittance  is  by  bank  check  or  postal  money  order  drawn 
to  tlie  order  of  the  undersigned.  Where  these  are  not  accessible,  remittances  for  the 
"Journal"  maybe  made  at  the  risk  of  the  publishers,  by  forwarding  in  registerei>. 
letters.     Address, 

Henry  C.  Lea's  Son  &  Co.,  Nos.  706  and  708  Sansom  St.,  Phlla.   Pa- 


4 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Dictio7iaries). 


JJUIsGLISON  {ROBLET),  M.D., 

Late  Professor  of  Institutes  of  Medicine  in  Jefferson  Medical  College,  Philadelphia. 

MEDICAL  LEXICON;  A  Dictionary  of  Medical  Science:  Con- 
taining a  concise  explanation  of  the  various  Subjects  and  Terms  of  Anatomy,  Physiology, 
Pathology,  Hygiene,  Therapeutics.  Pharmacology,  Pharmacy,  Surgery,  Obstetrics,  Medico] 
Jurisprudence,  and  Dentistry.     Notices  of  Climate  and  of  Mineral  Waters;  Formulae  for 
Officinal,  Empirical,  and  Dietetic  Preparations  ;  with  the  Accentuation  and  Etymology  of 
the  Terms,  and  the  French  and  other  Synonymes  ;  so  as  to  constitute  a  French  as  well  as 
English  Medical  Lexicon.     A  New  Edition.     Thoroughly  Revised,  and  very  greatly  Mod- 
ified and  Augmented.     By  Richard  J.  I>unglison,  M.D.     In  one  very  large  and  hand- 
someroyal  octavo  volume  of  over  1100  pages.    Cloth,  $6  50  ;  leather,  raised  bands,  $7  50  ; 
half  Russia,  $8.     (.Just  Issued.) 
The  object  of  the  author  from  the  outset  has  not  been  to  make  the  work  a  mere  lexi>;on  or 
dictionary  ofterms,  but  to  afford,  undereach,  a  condensedview  of  its  various  medical  relations, 
aad  thus  to  render  the  work  an  epitome  of  the  existing  condition  of  medical  science.    Starting 
wiDh  this  view,  the  immense  demand  which  has  existed  for  the  work  has  enabled  him,  in  repeated 
re/isions,  to  augment  its  completeness  and  usefulness,  until  at  length  it  has  attained  the  position 
of  a  recognized  and  standard  authority  wherever  the  language  is  spoken. 

Special  pains  have  been  taken  in  the  preparation  of  the  present  edition  to  maintain  this  en- 
viable reputation.  During  the  ttn  years  which  have  elapsed  since  the  last  revision,  the  additions 
to  the  nomenelature  ofthe  medical  scienceshave  been  greater  than  perhaps  in  any  similar  period 
of  the  past,  and  up  to  the  time  of  his  death  the  authorlabored  assiduously  to  incorporate  every- 
thing requiring  the  attention  of  the  student  or  practi  ioner.  Since  then,  the  editor  bus  been 
equally  industrious,  so  that  the  additions  to  the  vocnbulary  are  more  numerous  than  in  any  pre- 
vious revision.  Especial  attention  has  been  bestowed  on  the  accentuation,  which  will  be  found 
marked  on  every  word.  The  typ  igraphical  arrangement  has  been  much  improved,  rendering 
reference  much  more  easy,  and  evjry  care  has  been  taken  with  the  mechanical  execution.  The 
W'jrk  has  been  printed  on  new  type,  small  but  exceedingly  clear,  with  an  enlarged  pnge,  so  that 
the  additions  have  been  incorporated  with  an  increase  of  but  little  over  a  hundred  pages,  and 
the  volume  now  contains  the  matter  of  at  least  four  ordinary  octavos. 

oaay  eafely  confirm  the  hope  ventured  by  the  editor 
"  that  the  work,  whicli  pos.'^esses  fur  him  a  filial  as  well 
as  an  individual  ijiterest,  will  be  found  worthy  a  con- 
tinuance of  the  pof.itionso  lone;  accorded  to  it  as  a 
standard  authority." — Oincinnati  Clinic.  Jan.  10, 1S74. 
It  has  the  rare  merit  that  it  certainly  has  no  rival 


A.  book  well  known  to  our  readers,  and  of  which  I 
every  American  ought  to  be  proud.  When  the  learned 
author  of  the  work  passed  away,  probably  all  of  us 
feared  lest  the  book  should  not  maintain  its  place 
iu  the  advancing  science  whose  terms  it  defines.  For- 
tauately.  Dr.  Kichard  J.  Dunglison,  having  assisted  his 
father  in  the  revision  of  several  editions  of  the  work, 
and  having  been,  therefore,  trained  in  the  methods  and 
i.iibued  with  the  spirit  of  the  book,  has  been  able  to 
edit  it,  not  in  the  patchwork  manner  so  dear  to  the 
lieart  of  book  editors,  so  repulsive  to  the  taste  of  intel- 
ligent book  readers,  but  to  edit  it  as  a  work  ofthe  kind 
sliouldbe  edited — to  carry  it  on  steadily,  without  jar 
or  interruption,  along  the  grooves  of  thought  it  has 
travelled  (Juring  its  lifetime.  To  show  the  magnitude 
of  the  task  which  Dr.  Dunglison  has  assumed  and  car- 
ried through,  it  is  only  necessary  to  stale  that  more 
ttian  six  thousand  new  subjects  have  been  added  in  the 
presentedition. — Phila.  Med.  Times,  Jan   3,  1874. 

.\  bout  the  first  book  purchased  by  the  medical  stu- 
J  ent  is  the  Medical  Dictionary.  The  lexicon  explana- 
to-y  of  technical  terms  is  simply  a  sine  qua  non:  In  a 
Silence  so  extensive,  and  with  such  collaterals  as  medi 
cine,  it  is  as  much  a  necessity  also  to  the  practising 
pliysician.  To  meet  the  wants  of  students  and  most 
physicians,  the  dictionary  must  be  condensed  while 
comprehensive,  and  practical  while  perspicacious.  It 
was  because  Dunglison's  met  these  indications  that  it 
became  at  once  the  dictionary  of  general  use  wherever 
uiediciue  was  studied  in  the  English  language.  In  no 
fo-'.aer  re  vision  have  the  alterations  and  additions  been 
Bu  ,'reat.  Morethansixthousand  new  subjects  and  terms 
hive  been  added.  The  chief  terms  have  been  set  in  black 
letter,  while  the  derivatives  follow  in  small  caps;  an 
ai  r,iugement  which  greatly  facilitates  reference.    We 


in  the  English  language  for  accuracy  and  extent  of 
references. — London  Medical  Ctnzetff  . 

As  a  standard  work  of  reference,  as  one  of  the  best, 
if  not  the  very  best,  medical  dictionary  in  the  Eng- 
lish language,  Dunglison's  work  has  been  well  known 
for  about  forty  years,  and  ueeds  no  words  of  praise 
on  our  part  to  recommend  it  to  the  members  of  the 
medical,  and,  likewise,  of  the  pharmaceutical  pro- 
fession. The  latter  especially  are  in  need  of  such  a 
work,  which  gives  ready  and  reliable  informHtiun 
on  thousands  of  subjects  and  terms  which  they  are 
liable  to  encounter  in  pursuing  their  daily  avoca- 
tions, but  with  which  they  cannot  be  expected  to  be 
familiar.  The  work  before  us  fully  supplies  this 
want. — Ara.  Journ.  of  Pharm.,  Feb.  1874. 

A  valuable  dictionary  of  the  terms  employed  in 
medicine  and  the  allied  scienres,  and  of  the  ri  la- 
tions  of  the  subjects  treated  under  each  head.  It  re- 
flects great  credit  on  its  able  American  author,  and 
well  deserves  the  authority  and  popularity  it  has 
obiaXuei.— British  Med.  Journ., Oct.  31,  1874. 

Few  works  of  this  class  exhibit  a  grander  monu- 
ment of  patient  research  and  of  scientific  lore.  The 
extent  ofthe  sale  of  this  lexicon  is  sufficient  to  tes- 
tify to  its  use'ulness,  and  to  the  great  service  con- 
ferred by  Dr.  R.)bley  Dunglison  on  the  profession, 
and  indeed  on  others,  by  iiB  issue. — London  LuncH, 
May  13   1875. 


LJOBLYN  [RICHARD  D.),  M.D. 
'^^A  DICTIONARY  OF  THE  TERMS  USED  IN  MEDICINE  AND 

THE  COLLATERAL  SCIENCES.  Revised,  with  numerous  additions,  by  Isaac  Hays, 
M.D.,  Editor  ofthe  "American  Journal  of  the  Medical  Sciences."  In  one  large  royal 
l2mo.  volume  of  over  500  double-columned  pages  ;  cloth,  $1  60  ;  leather,  $2  00 

It  is  the  best  book  of  definitions  we  have,  and  ought  always  to  be  upon  the  student's  table.— Sowttem 
Jfe.d.  and  Hury  Journal. 

I   ODWELL  [G.  F.),  F.R.A.S.,  ^c. 
^'    A  DICTIONARY  OF  SCIENCE:  Comprising  Astronomy,  Chem- 

istry.  Dynamics,  Electricity,  Heat,  Hydrodynamics,  Hydrostatics,  Light,  Magnetism, 
Mechanics,  Meteorology,  Pneumatics,  Sound,  and  Statics.  Preceded  by  an  Essay  on  the 
History  of  the  Physical  Sciences.  In  one  handsome  octavo  volume  of  694  pages,  with 
many  illustrartionE :  cloth,  $5. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (ManuaU).  5 

A  CENTURY  OF  AMERICAN  MEDICINE,  1770-1876.  By  Doctors  E.  H. 
•^-'-  Clarke,  H.  J.  Bigelow,  S.  D.  Gross,  T.  G.  Thomas,  andJ.  S.  Billings.  Inone  very  hand- 
some 12mo.  volume  of  about  350  pages  :  cloth,  $2  25.      (Lately  Issuetl.) 

This  work  appeared  in  the  pages  of  the  American  Journal  of  the  Medical  Sciencesduring  the 
year  1876.  As  a  detailed  account  of  the  development  of  medical  science  in  America,  by  gentle- 
men of  the  highest  authority  in  their  respective  departments, .the  profession  will  no  doubt  wel- 
oome  i't  in  a  form  adapted  for  preservation  and  reference. 


ISTEILL  {JOHN),  M.D.,  and    J^MITH  {FRANCIS  G.),  M.D., 

•^  Prof  .of  thelnstUuteeof  Medicine  intheUniv.of  Penna 

AN    ANALYTICAL    COMPENDIUM   OF   THE    VARIOUS 

BRANCHES  OP  MEDICAL  SCIENCE;  for  the  Use  and  Examination  of  Students.  A 
new  edition,  revised  and  improved.  In  one  very  large  and  handsomely  printed  royal  I2iiJo. 
volume,  of  about  one  thousanu  pages,  with  374  wood-cuts,  cloth,  $4  j  strongly  bound  in 
leather,  with  raised  bands,  $4  75. 


TJARTSHORNE  {HENRY),  M.D., 

Professor  of  Hygiene  in  the  University  of  Pennsylvania. 

A    CONSPECTUS    OF    THE    MEDICAL   SCIENCES;    containing 

Handbooks  on  Anatomy,  Physiology,  Chemistry,  Materia  Medica,  Practical  Medicine, 
Surgery,  and  Obstetrics.  Second  Edition,  thoroughly  revised  and  improved.  In  one  large 
royal  12mo.  volume  of  more  than  1000  closely  printe<l  pages,  with  477  illustrations  on 
wood.     Cioth,  $4  25  ;  leather,  $5  00.     {Lately  Issued.) 

worthy.    If  students  must  have  a  conspectas,  they 

will  be  wise  to  procure  that  of  Dr    Hartsborne 

Detroit  Rev.  of  Med.  and  Pkarm. ,  Aug   1874 

The  work  before  us  has  many  redeeming  features 
not  possessed  by  oiherh,  and  is  the  best  we  have 
seen.  Dr.  Hartshorne  exhibits  much  skill  in  con- 
densation.   It  is  well  adapted  to  the  physician  in 


We  can  say  with  the  strictest  truth  that  it  Is  the 
best  work  of  the  kind  with  which  wt  artacqnainted. 
It  embodies  in  a  condensed  form  all  recent  cent I'ibu- 
tions  to  practical  medicine,  and  is  therefore  useful 
to  every  busy  practitioner  throughout  our  country, 
besides  being  admirably  adapted  to  the  use  of  stu- 
dents of  medicine.  The  book  is  faithfully  and  ably 
executed. — Charleston  Med.  Journ.,  April,  1875. 

The  work  is  Intended  as  an  aid  to  the  medical 
student,  and  as  such  appears  to  admirably  fulfil  its 
object  by  its  excellent  arrangement,  the  full  compi- 
lation of  facts,  the  perspicuity  and  terseness  of  lan- 
guage, and  the  clear  and  instructive  illustrations 
in  some  parts  of  the  work — American  Journ.  of 
Pharmacy,  Philadelphia,  July,  1874. 

The  volume  will  be  found  useful,  not  only  to  stu- 
dents, bat  to  many  otherswhomay  desire  torefresh 
their  memories  with  the  smallest  possible  expendi- 
ture of  time.— iV^.  F.  Med.  Journal,  Sept.  1874. 

The  student  willflnd  this  the  mostconvenient  and 
useful  book  of  the  kind  on  which  he  can  lay  hit 
hand. — Pacific  Med.  and  Surg.  Journ.,  Aug.  1874. 

This  is  the  best  book  of  its  kind  that  we  have  ever 
examined.  It  is  an  honest,  accurate,  and  concise 
compend  of  medical  sciences,  as  fairly  as  possible 
representing  their  present  condition.  The  changes 
and  the  additions  have  been  so  judicious  and  tho- 
rough as  to  render  it, so  far  as  it  goes,  entirely  trust- 


active  practice,  who  can  give  but  limited  time  to  the 
familiarizing  of  himself  with  the  important  changes 
which  have  been  made  since  he  attended  lectures. 
The  manual  of  physiology  has  also  been  improved 
and  gives  the  most  comprehensive  view  of  the  late^  t 
advances  in  the  science  possible  in  the  space  devoted 
to  the  subject.  The  mechanical  execution  of  the 
book  leaves  nothing  to  be  wished  tor.— Peninsular 
Journal  of  Medicine,  Sept.  1S74. 

After  carefully  looking  through  this  conspectus, 
we  are  constrained  to  say  that  it  is  the  most  com- 
plete work,  especially  in  its  illustrations,  of  its  kind 
that  we  have  seen. — Cincinnati  Lancet,  Sept.  1S74. 

The  favor  with  which  the  first  edition  of  this 
Compendium  was  received,  was  an  evidence  of  its 
various  excellences.  The  present  edition  bears  evi- 
dence of  a  careful  and  thorough  revision.  Dr.  Harts- 
borne  possesses  a  happy  faculty  of  seizing  upon  the 
salient  points  of  each  subject,  and  of  presenting  them 
in  a  concise  and  yet  perspicuous  manner. — Leaven- 
worth Med.  Heracd,  Oct.  1874 


rUDLOW  {J.L.),  M.D. 
A   MANUAL   OF  LAMINATIONS  upon  Anatomy,  Physiology, 

Surgery,  Practice  of  Medicine,  Obstetrics,  Materia  Medica,  Chemistry,  Pharmacy,  and 
Therapeutics.  To  which  is  added  a  Medical  Formulary.  Third  edition,  thoroughly  revised 
and  greatly  extended  and  enlarged.  With  370  illustrations.  In  one  handsome  royal 
12mo.  volume  of  816  large  pages.  Cloth,  $3  25  ;  leather,  $3  75. 
The  arrangement  oi  this  volume  in  the  form  of  question  and  answer  renders  it  especially  suit- 
able for  the  ofiBee  examination  of  students,  and  for  those  preparing  for  graduation. 


/TANNER  {THOMAS  HAWKES),  M.D.,  §-c. 

A  MANUAL  OF  CLINICAL  MEDICINE  AND  PHYSICAL  DIAG- 
NOSIS.   Third  American  from  the  Second  London  Edition.    Revised  and  Enlarged  by 
Tilbury  Fox,  M.  D.,  Physician  to  the  Skin  Department  in  University  College  Hospital, 
L)ndon,  <fcc.   In  one  neat  volume  small  ]2mo.,  of  about  375  pages,  cloth,  $150. 
*:)(:*  On  page  3,  it  will  be  seen  .that  this  work  is  offered  as  a  premium  for  procuring  new 
eabscribers  to  the  "American  Journal  op  the  Medical  Sciences." 


6  Henry  C.  Lea's  Son  &  Co.'s  Publications — (Anatomy). 

QR-^y  [HENRY),  F.R.S., 

Lecturer  on  Anatomy  at  St.  Oeorge'a  Hospital,  London. 

ANATOMY,  DESCRIPTIVE    AND  SURGICAL.     The  Drawings  by 

H.  V.  Cartbe,  M.D.,and  Dr.  Westmacott.   The  Dissections  jointly  by  the  Author  and 
Dr.  Carter.     With  an   Introduction    on    General   Anatomy  and  Development  by  T. 
Holmes,  M.A.,  Surgeon-to  St.  George's  Hospital.     A  new  American,  from  the  Eighth 
enlarged  and  improved  London  edition.     To  which  is  added  "  Landmarks,  MEDieAL  and 
Surgical,"  by  Luther  Holden,  F.R.C.S.,  author  of  "Human  Osteology,"  "A  Manual 
of  Dissections,"   etc.     In  one  magnificent  imperial  octavo  volume  of  983  pages,  with 
522  large  and  elaborate  engravings  on  wood.     Cloth,  $6;  leather,  raised  bands,  $7; 
half  Russia,  $7  60.     (Now  Ready.) 
The  author  has  endeavored  in  this  work  to  cover  a  more  extendedrange  of  subjects  than  is  cus- 
tomary in  the  ordinary  text-books,  by  giving  not  only  the  details  necessary  for  the  student,  but 
also  the  applicationof  those  detailsin  the  practiceof  medicine  andsurgery,  thusrendering  it  both 
a  guide  for  the  learner,  and  an  admirable  work  of  reference  for  the  active  practitioner.  The  en- 
gravings form  a  special  feature  in  the  work,  many  of  them  being  the  size  of  nature,  nearly  all 
original,  and  having  the  names  of  the  various  parts  printed  on  the  body  of  the  cut,  in  place  of 
figures  of  reference,  with  descriptions  at  the  foot.  They  thus  form  a  complete  and  splendid  series, 
which  will  greatly  assist  the  student  in  obtaining  a  clear  idea  of  Anatomy,  and  will  also  serve  to 
refresh  the  memory  of  those  who  may  find  in  the  exigencies  of  practice  the  necessity  of  recalling 
the  details  of  the  dissecting  room  j  while  combining,  as  it  does,  a  complete  Atlas  of  Anatomy,  with 
a  thorough  treatise  on  systematic,  descriptive,  and  applied  Anatomy,  the  vyorkwill  be  found  of 
essential  use  to  all  physicians  who  receive  students  in  their  offices,  relieving  both  preceptor  and 
pupil  of  mifch  labor  in  laying  the  groundwork  of  a  thorough  medical  education. 

Since  the  appearance  of  tha  last  American  Edition,  the  work  has  received  three  revisions  at  the 
hands  of  its  accomplished  editor,  Mr.  Holmes,  who  has  sedulously  introduced  whatever  has  seemed 
requisite  to  maintain  its  reputation  as  a  complete  and  authoritative  standard  text-book  and  work 
of  reference.  Still  further  to  increase  its  usefulness,  there  has  been  appended  to  it  the  recent 
work  by  the  distinguished  anatomist,  Mr.  Luther  Holden — "Landmarks,  Medical  and  Surgical" 
which  gives  in  a  clear,  condensed  and  systematic  way,  all  the  information  by  which  the  prac- 
titioner can  determine  from  the  external  surface  of  the  body  the  position  of  internal  parts.  Thus 
complete,  the  work,  it  is  believed,  will  furnish  all  the  assistance  that  can  be  rendered  by  type  and 
illustration  in  anatomical  study.  No  pains  have  been  spared  in  the  typographical  execution  of 
the  volume,  which  will  be  found  in  all  respects  superior  to  former  issues.  Notwithstanding  the 
increase  of  size,  amHjunting  to  over  100  pages  and  57  illustrations,  it  will  be  kept,  as  heretofore, 
at  a  price  rendering  it  one  of  the  cheapest  works  ever  offered  to  the  American  profession. 

The  recent  work  of  Mr  Holden,  which  was  no-  i  to  consult  his  books  on  anatomy.  The  work  is 
ticed  by  us  on  p.  53  of  this  volume,  has  been  added  simply  indispensable,  especially  this  present  Amer- 
as  an  appendix,  so  that,  altogether,  this  i.s  the  mott    ican  edition.— Ta.  Med.  Monthly,  Sept.  1878. 


practical  and  complete  anatomical  treatise  available 
to  American  students  and  phy.-icians.  The  former 
finds  in  it  the  necessary  guide  in  making  dissec- 
tions ;  a  very  comprehensive  chapter  on  minnte 
anatomy;  and  about  all  that  can  be  taught  him  ou 
general  and  special  anatomy;  while  the  latter,  in 
its  treatment  of  each  region  from  a  surgical  point  of 
view,  and  in  the  valuable  addition  of  Mr.  Holden, 
will  find  all  that  will  be  essential  to  him  in  his 
practice  — New  Remedies,  Aug.  187S. 

This  work  is  as  near  perfection  as  one  could  pos- 
sibly or  reasonably  expect  any  book  intended  as  a 
text-book  or  a  general  reference  book  on  anatomy 
to  be.  The  American  publisher  deserves  the  thanks 
of  the  profession  for  appending  the  recent  work  of 
Mr.  Holden,  "  Landmarkd;  Medical  and  S'lt gioal," 
which  has  already  been  commended  as  a  separate 
book.  The  latter  work  — trenting  of  topographical 
anatomy — has  become  hu  essential  to  the  library  of 
every  intelligent  practitioner.  We  know  of  no 
book  that  can  take  its  place,  written  as  it  is  by  a 
most  distinguished  anatomist.  It  would  be  simply 
a  waste  of  words  to  say  anything  further  in  praise 
of  Gray's  Anatomy,  the  text-book  in  almost  every 
medical  college  in  this  country,  and  the  daily  refer 
eace  book  of  every  practitioner  who  has  occasion 


The  addition  of  the  recent  work  of  Mr.  Holden, 
as  an  appendix,  renders  this  the  most  practical  and 
complete  treatise  available  to  American  students, 
who  find  in  it  a  comprehensive  chapter  on  minute 
anatomy,  about  all  that  can  be  taught  on  general 
and  special  anatomy,  while  its  treatment  of  each 
region,  from  a  surgical  point  of  vieiv,  in  the  valu- 
able section  by  Mr  Holden,  is  al.1  that  will  be  essen- 
tial to  them  in  practice. — Ohio  Medical  Recorder, 
Aug  1878. 

It  is  difflcuU  to  speak  in  moderate  terms  of  this 
new  edition  of  "GrHy."  It  seems  to  be  as  nearly 
perfect  as  it  is  possible  to  make  a  book  devoted  to 
any  branch  of  medical  science.  The  labors  of  the 
eminent  men  who  have  siiccessively  revised  the 
eight  editions  through  which  it  has  passed,  would 
seem  to  leave  nothing  for  future  editors  to  do.  The 
addition  of  Holden's  "Landmarks"  will  make  it  as 
indispensable  tn  the  practitioner  of  medicine  and 
surgery  as  it  has  been  heretofore  to  the  student.  As 
regards  completeness,  ease  of  reference,  utility, 
beauty,  and  cheapness,  it  has  no  rival.  No  stn- 
dftnt  should  enter  a  medical  school  without  it ;  no 
physician  can  afford  to  have  it  absent  from  his 
library  — St.  Louis  Clin.  Record,  Sept.  1878. 


Also  for  sale  separate — 
TTOLDEN  [LOT HER),  F.R.C.S., 

J--'-  Surgeon  to  St.  Bartholomew's  and  the  Foundling  Hospitals. 

LANDMARKS,  MEDICAL  AND  SURGICAL.  From  the  2d  London 

Ed.   Inonehandsome  volume,  royal  12mo.,  of  128  pages.  Cloth,  88  cents.    {Now  Ready.) 

TJEATR  {CHRISTOPHER),  F.R.C.S., 

-'■-*■  Teacher  of  Operative  Surgery  in  University  College,  London. 

PRACTICAL  ANATOMY:   A  Manual  of  Dissections.     From  the 

Second  revised  and  improved  London  edition.  Edited,  with  additions,  by  W.  W.  Keen, 
M.  D.,  Lecturer  on  Pathological  Anatomy  in  the  Jefferson  Medical  College,  Philadelphia. 
In  one  handsome  royal  I2mo. volume  of  678  pages,  with  247iIluEtrations.  Cloth,  $3  60; 
leather,  $4  00. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Anatomy). 


A  LLEN  (HAERISON),  M.D. 

■^-^  Profesfior  of  Phyniology  in  the,  Univ.  of  Pa. 

A  SYSTEM  OF  HUMAN  ANATOMY:  INCLUDING  ITS  MEDICAL 

and  Surgical  Relatidns.  For  the  Use  of  Practitioners  and  Studentsof  Medicine     With  sin 
Introductory  Chapter  on  Histology.  By  E.  0.  Shakkspkare,  M  D  ,  OphtbMlmologistto  the 
Phila.  Hosp.    In  one  la.rge  and  hnndsotne  quarto  volume,  with  several  hundred  orieinal 
illustrations  on  lithographic  plates,  and  numerous  wood-cuts  in  the  text.      [Skortly.) 
In  this  elaborate  work,  which  has  been  in  active  preparation  for  several  years,  the  author  has 
sought  to  give,  not  only  the  details  ofdescriptive  anatomy  in  a  clearnnd  condensed  form,  but  also 
the  practical  applied tions  of  the  science  to  medicine  and  surgery.  The  work  thus  has  claims  upon 
the  attention  of  the  general  practitioner,  as  well  as  of  the  student,  enabling  him  not  only  to  re- 
fresh his  recollections  of  the  dissecting  room,  but  also  to  recognize  the  significance  of  all  varia- 
tions from  normal  conditions.     The  marked  utility  of  the  object  thus  sought  by  the  author  is 
self-evident,  and  his  long  experience  and  assiduous  devotion  to  its  thorough  development  are  a 
BufBcienl  guarantee  of  the  manner  in  which  his  aims  have  been  carried  out.  No  pains  have  been 
spared  with  the  illustrations.  Those  of  normal  anatomy  are  from  original  di.isections,  drawn  on 
stone  by  Mr.  Hermann  Faber,  with  the  name  of  every  part  clearly  engraved  upon  the  figure 
after  the  manner  of  "  Holden"  and  "  Gray, "  and  in  every  typographical  detail  it  will  be  the 
efiFort  of  the  publishers  to  render  the  volume  worthy  of  the  very  distinguished  position  which  is 
anticipated  for  it. 

fpiLIS  [GEORGE   VINER). 

-*-'  Emeritus  Professur  of  Anatomy  in  University  College,  London. 

DEMONSTRATIONS  OF  ANATOxMY;  Being  a  Guide  to  the  Know- 

ledge  of  the  Human  Body  by  Dissection.  By  George  Viner  Ei.lis,  Emeritus  Professor 
of   Anatomy  in    University  College,    London.     From  the   Eighth  and  Revised  London 
Edition.     In  one  very  handsome  octavo  volume  of  over  700  pages,  with  256  illustrations. 
Cloth,  $4.26  ;  leather,  $5.25     '  {Now  Ready.) 
This  work  has  long  been  known  in  England  as  the  leading  authority  on  practical  anatomy, 
and  the  favorite  guide  in  the  disseeting-roora,  as  is  attested  by  the  numerous  editions  through 
which  it  has  passed.     In  the  last  revision,  which  has  just  appeared  in  London,  the  accomplished 
author  has  sought  to  bring  it  on  a.  level  with  the  most  recent  advances  of  science  by  making  the 
necessary  changes  in  his  account  of  the  microscopic  structure  of  the  different  organs,  as  devel- 
oped by  the  latest  researches  in  textural  anatomy. 
Ellis's  Demonstrations  is  the  favorite  text-book    its  leadership  over  the  English  manuals  upon  dis- 


of  the  English  student  of  anatomy.  In  passing 
through  eight  editions  it  has  been  so  revised  and 
adapted  to  the  needs  of  the  student  that  it  would 
seem  that  it  had  almost  reached  peifection  in  \\\\i 
special  line.  The  desciiptions  are  clear,  and  the 
methods  of  pursuing  anatomical  investigations  are 
given  with  such  detail  that  the  book  is  honestly 
entitled  to  its  name. — St.  Louis  Clinical  Record, 
Jane,  1879. 

The  success  of  this  old  manual  seems  to  be  as  well 
deserved  in  the  present  as  in  the  past  volumes. 
The  book  seems  destined  to  maintain  yet  for  years 


secting. — Phila.  Med.  Times,  May  24,  1879. 

As  a  di.«sector,  or  a  work  to  have  in  hand  and 
studied  while  one  is  engaged  in  dissecting,  we  re- 
gard it  as  the  very  best  work  extant,  which  is  cer- 
tainly saying  a  very  great  deal.  As  a  text-book  to 
be  studied  in  the  dissecting-room,  it  is  superior  io 
any  of  the  works  upon  anatomy.— Cmcinnatt  Med. 
News,  May  24,  1879. 

We   most  unreservedly  recommend   it  to   every 

practitioner  of  medicine  who  can  pdfesibly  get  It. 

Va..  Med.  Monthly,  June,  1879. 


7ILS0N  {ERASMUS),  F.R.S. 
A  SYSTEM  OF  HUMAN  ANATOMY,  General  and  Special.  Edited 

by  W.  H.  GoBRECHT,  M.D.,  Professor  of  General  and  Surgical  Anatomy  in  the  Medical  Col- 
lege of  Ohio.  Illustrated  with  three  hundred  and  ninety-seven  engravings  on  wood.  In 
one  large  and  handsome  octavo  volume,  of  over  600  pages  ;  cloth,  $4  ;  leather,  $5. 


and  JJORNER  (  WILLIAM  E.),M.D., 

Late  Prof,  of  Anatomy  in  the  Univ.  ofPenna. 


^MITH  [HENRY H.),  M.D., 

Prof,  of  Surgery  in  the  Univ.  of  Penna. ,  &o. 

AN   ANATOMICAL   ATLAS  ;    Illustrative  of  the  Structure  of  the 

Human  Body.  In  one  volume,  large  imperial  octavo,  cloth,  with  about  six  hundred  and 
fifty  beautilul  figures.     $4  50. 

fyCHAFER  [ED  WARD  ALBERT),  M.D., 

^  Assistant  Profetsor  of  Physiology  in  University  College,  London. 

A  COURSE  OF  PRACTICAL  HISTOLOGY:  Being  an  Introduction  to 

the  Use  of  the  Microscope.     In  one  handsome  royal  12mo.  volume  of  304  pages   with 
numerous  illustrations:  cloth,  $2  00.     (Just  Issued.) 


HORNER'S  SPECIAL  ANATOMY  AND  HISTOL- 
OGY. Eighth  edition,  extensively  revised  and 
modified.  In  2  vols.  8vo.,  of  over  1000  pages, 
with  320  wood-cuts  :  cloth,  ijifi  00 

SHARPEY  AND  QUAIN'S  HUMAN  ANATOMY. 
Revised,  by  Joseph  Leidt,  M.D.,Prof  of  Anat. 
in  Dn  iv.  of  Penn.  In  two  octavo  vols,  of  about 
1800  pages,  with  .511  illustrations     Cloth,  $6  00. 

BELLAMY-S  STUDENT'S  G0IDE  TO  SURGICAL 
ANATOMY  :  A  Text  book  for  Students  preparing 


for  their  Pass  Examination,  With  engravings  on 
wood  In  one  handsome  royal  12mo.  volume. 
Cloth,  $2  2.5. 

CLELAND'S  DIRECTORY  FOR  THE  DISSECTION 
Of  THE  HUMAN  BODY.  In  one  small  volume, 
royal  12mo.  of  182  pages:  eloth  SCI  25. 

HARTSHORNE'S  HANDBOOK  OP  ANATOMY  AND 
PHISIOLOGY.  Second  edition,  revised.  In  one 
royal  12ino.  vol.,  with  220  woodcuts;  cloth. 
$1  i6. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — {Physiology). 


fkALTON  {J.  C),  M.D., 

-*^  Professor  of  Physiology  in  the  College  of  Physicians  and  Surgeons,  New  Torlt,  &e. 

A  TREATISE  ON  HUMAN  PHYSIOLOGY.    Designed  for  the  use 

of  Studentsand  Practitioners  of  Medicine.  Sixth  edition,  thoroughly  revised  and  enlarged, 
with  three  hundred  and  sixteen  illustrations  on  wood.  In  one  very  beautiful  octavo  vol- 
ume, of  over  800  pages.  Cloth,  $5  50;  leather,  $6  50;  half  Russia,  $7.  iLatehj  Issued.) 


During  the  past  few  years  several  new  works  on  phy- 
siology, and  new  editions  of  old  works,  have  appeared, 
competing  for  the  I'avor  of  the  medical  student,  but 
none  will  rival  this  new  edition  of  Dalton.   As  now  en- 


larged, it  will  be  found  also  to  be, in  general,  a  satisfac-.  of  the  work  is  all  that  could  be  desired. — Peninsular 


tory  work  of  reference  for  the  practitioner. — Chicago 
Med.  Journ.  and  Examiner,  Jan.  1 876. 

Prof.  Dalton  has  discussed  conflicting  theories  and 
conclusions  regarding  physiological  questions  with  a 
fairness,  a  fulness,  and  a  conciseness  which  lend  fresh- 
ness and  vigor  to  the  entire  book.  But  his  discussions 
have  been  so  guarded  by  a  refusal  of  admission  to  those 
speculative  and  theoretical  explanations,  which  at  best 
exist  in  the  minds  of  observers  themselves  as  only  pro- 
babilities, that  none  of  his  readers  need  be  led  into 
grave  errors  while  making  them  a  study. — The  Medical 
Record,  Feb.  19, 1876. 

The  revision  ofthisgreatworkhasbroughtitforward 
with  the  physiological  advances  of  theday,  andreuders 
it,  as  it  has  ever  been,  the  finest  work  for  students  ex- 
tant.— Nashville  Journ.  of  Med.  and  Surg.,  Ja,n.  1876. 

For  clearness  and  perspicuity,  Dalton's  Physiology 
commended  itself  to  the  student  years  ago,  and  was  a 
pleasant  relief  from  the  verbose  productions  which  it 
supplanted.  Physiology  has,  however,  made  many  ad- 
vances since  then — and  while  the  style  has  been  pre- 
served intact,  the  work  in  the  present  edition  has  been 
brought  up  fully  abreastof  the  times.  Thenew  chemical 


notation  and  nomenclatxire  have  also  been  introduced 
into  the  present  edition.  Notwithstanding  the  multi- 
plicity of  text-books  on  physiology. this  will  lose  none 
of  its  old  time  popularity.    The  mechanical  execution 


Journal  of  Medicine,  Dec.  1875. 

This  popular  text-book  on  physiology  comes  to  us  in 
its  sixth  edition  with  the  addition  of  about  fifty  per  cent, 
of  new  matter,  chiefly  in  the  departments  of  patho- 
logical chemistry  and  the  nervous  system,  where  the 
principal  advances  have  been  realized.  With  so  tho- 
rough revision  and  additions,  that  keepthe  work  well 
up  to  the  times,  its  continued  popularity  may  be  confi- 
dently predicted,  notwithstanding  the  competition  it 
may  encounter.  The  publisher's  work  is  admirably 
done. —  St.  Louis  Med. and  Surg.  Journ, Dec.  1875. 

We  heartily  welcome  this,  the  sixth  edition  of  this 
admirabletext-book.than  which  thereare  noneofequal 
brevity  more  valuable.  It  i.s cordially  recommended  by 
the  Professor  of  Physiology  in  theUniversity  of  Louisi- 
ana, as  by  all  competent  teachers  in  theUnited  States, 
and  wherever  the  English  language  is  read,  this  book 
has  been  appreciated.  The  present  edition,  with  its  316 
admir.ably  executed  illustrations,  has  been  carefully 
revised  and-very  much  enlarged,  although  its  bulk  does 
not  seem  perceptibly  increased. — New  Orleans  Medical 
and  Surgical  Journal,  March,  1876 . 


pAEPENTER  [WILLIAM  B.),  M.D.,  F.R.S.,  F.G.S.,  F.L.S., 

^  Registrar  to  University  of  London,  etc. 

PRINCIPLES  OF  HUMAN  PHYSIOLOGY;  Edited  by  HenryPower, 

M.B.  Lond.,  F.R.C.S.,  Examiner  in  Natural  Sciences,  University  of  Oxford.  Anew 
American  from  the  Eighth  Revised  and  Enlarged  English  Edition,  with  Notes  and  Addi- 
tions, by  Francis  G.  Smith,  M.D.,  Professor  of  the  Institutes  of  Medicine  in  the  Univer- 
sity  of  Pennsylvania,  etc.  In  one  very  large  and  handsome  octavo  volume,  of  1083  pages, 
with  two  plates  and  373  engravings  on  wood.  Cloth,  $6  50  ;  leather,  $6  50  ;  half  Russia, 
$7.     {Just  Iss2ied.) 


We  have  been  agreeably  surprised  to  find  the  vol- 
ume so  complete  in  regard  to  the  structure  and  func- 
tions of  the  nervous  system  in  all  its  relations,  a 
subject  that,  in  many  respects,  is  one  of  the  most  diffi- 
cult of  all,  in  the  whole  range  of  physiology,  upon 
which  to  produce  a  full  and  satisfactory  treatise  of 
the  class  to  which  the  one  before  ns  belongs.  The 
additions  by  the  American  editor  give  to  the  work  as 
it  is  a  considerable  value  beyond  that  of  the  last 
English  edition.  In  conclusion,  we  can  give  our  cor- 
diitl  recommendation  to  the  work  as  it  now  appears. 
The  editors  have,  with  their  additions  to  the  only 
work  on  physiology  in  our  language  that, in  thefull- 
est  sen-e  of  the  word,  is  the  production  of  a  philoso- 
pher as  well  as  a  physiologist,  brought  it  up  as  fully 
as  could  be  expected,  if  not  desired,  to  the  standard 
of  our  knowledge  of  its  subject  at  the  present  day. 
It  will  deservedly  maintain  the  place  it  has  always 
had  iu  the  favor  of  the  medical  profession. — Journ. 
of  Nervous  and  Mental  Ditease,  April,  1877. 

Suehenormousadvances  have  recently  been  made  in 
our  physiological  knowledge,  that  what  was  perfectly 


new  a  year  or  two  ago.  looks  now  as  if  it  had  been  a 
received  and  established  fact  for  years.  In  this  ency- 
olopredic  way  it  is  unrivalled.  Here,  as  it  seems  to 
us,  is  the  great  value  of  the  book;  one  is  safe  in  sending 
a  student  to  it  for  information  on  almost  any  given 
subject,  perfectly  certain  of  the  fulness  of  information 
it  will  convey,  and  well  satisfied  of  the  accuracy  with 
which  it  will  there  be  found  stated. — London  Med. 
Timef  and  Gazette,  Feb.  17, 1877. 

The  merits  of  "  Carpenter'sPhysiology"  are  so  widely 
known  and  appreciated  ihat  we  need  only  allude  briefly 
to  the  fact  that  in  the  latest  edi* ion  will  be  found  a  com- 
prehensive embodiment  of  the  results  of  recent  physio- 
loifical  investigation.  Care  has  been  taken  to  preserve 
the  practical  character  of  the  original  work.  In  fact 
the  entire  work  has  been  brought  up  to  date,  and  bears 
evidence  of  the  amount  of  labor  that  has  been  bestowed 
upon  it  by  its  distinguished  eilitor,  Mr.  Henry  Power. 
The  American  editor  has  made  the  latest  additions,  in 
order  fully  to  cover  the  time  that  has  elapsed  since  the 
last  English  edition. — iV.  Y.  Med.  Journal, 3 s.n  .ISIT . 


J^OSTER  [MICHAEL),  M.D.,  F.R.S., 

J-  Prof,  of  Physiology  in  Cambridge  Univ.,  England. 

TEXT-BOOK    OF    PHYSIOLOGY.     Latest   edition.     In  one   hand- 
some 12mo.  vol.  of  over  800  pages,  with  72  illustrations.     Cloth,  $3  00'.     {J^tst  Ready.) 
Dr.  Foster  has  combined  in  this  work  'he  conflict-  '  commend  it,  both  to  the  student  and  the  practitioner, 
in g  desiderata  in   all   text-books— comprehensive-    as  beingone  of  ttiebe.st  text-books  on  physiology  ex- 
ness,    brevity,    and    clearness.       After    a    careful  j  tant.  —  The  Ljndon  Lancet. 
perusal  of  the  whole  work  we  can  confidently  re-  | 


LEHMANK'S  MANUAL  OF  CHEMICAL  PHYSIOL- 
OGY. Translated  from  the  German,  with  Sfotes 
and  Additions,  by  J.  Cheston  Morris,  M.D.  With 
Ulustrations  on  wood.  In  one  octavo  volume  o( 
336  pages.     Cloth,  $2  25. 


LEHMANN'S  PHYSIOLOGICAL  CHEMISTRY.  Com- 
plete  in  two  large  octavo  volumes  of  1200  pages, 
with  200  illustrations;  cloth,  $6. 


Henry  C.  Lea'8  Son  &  Co.'s  Publications — (  Ghemistry). 


9 


A  TTFIELD  {JOHN),  Ph.D., 

•^^  Prufe.xfor  of  PratMcal  Ohemistryto  the  Pharmaceutical  Society  of  Oreat  Britain,  Ac. 

CHEMISTRY,  GENERAL,  MEDICAL,  AND  PHARMACEUTICAL; 

Including  theChemi.ftry  of  the  U.  8.  Pharmacopceia.  A  Manual  of  the  General  Principles 
of  the  Science,  and  their  Application  to  Medicine  and  Pharmacy.  Eighth  edition,  revised 
by  the  author.  In  one  handsome  royal  12mo.  volume  of  700  pages,  with  illustrations. 
Cloth,  $2  50  ;  leather,  $3  00.      (Now  Ready.) 


We  have  repeatedly  exprensed  our  favorable 
opinion  of  this  work,  and  on  the  appearance  of  a 
new  edition  of  it,  little  remainB  for  ns  to  say,  ex- 
cept that  we  expect  this  eighth  edition  to  be  as 
indispensHble  to  us  as  the  seventh  and  previous 
editions  have  been.  While  the  sieaeral  plan  aod 
arrangement  have  been  adhered  to,  new  matter 
has  been  added  covering  the  observations  made 
since  the  former  edition  The  present  differs  from 
tbe  precediDg  one  chiefly  in  these  alterations  and 
in  aborft  ten  pages  of  useful  tables  added  in  the 
appendix  —Am.  Jour,  of  Pharmacy,  May,  1879. 

A  standard  work  like  Attfield's  Chemistry  need 
only  be  mentioned  by  its  name,  without  further 
commeats.  The  present  edition  contains  such  al- 
terations and  additions  as  seemed  necessary  for 
the  demonstration  of  the  latest  developments  of 
chfmical  prinfiples,  and  the  latest  applications  of 
cbemistry  to  pharmacy.  The  author  has  bestowed 
arduons  labor  on  the  revision,  and  the  extent  of 
the  information  thus  introduced  may  be  estimated 
from  the  fact  that  the  index  contains  three  hun- 
dred new  references  relating  to  additional  mater- 
ial.—Z)i-".g'5ri6'fA'  Circular  and  Ghemioal  Gaziitte, 
May,  1879, 


of  chemistry  In  all  the  medical  collpgee  in  the 
United  States.  The  present  edition  contains  such 
alterations  and  addition«  as  seemed  necessary  for 
the  demonstration  of  the  latef^t  developments  of 
chemical  principles,  and  the  latest  applications  of 
chemistry  to  pharmacy.  It  Is  scarcely  necessary 
for  us  to  say  that  it  exhibits  chemistry  in  its  pre- 
sent ad  VR  need  state. — Cincinnati  Medical  iftwe, 
April,  1879. 

The  popularity  which  this  work  has  enjoyed  is 
owing  to  the  origiual  and  clear  disposition  of  the 
facts  of  the  science,  the  accuracy  of  the  details,  and 
the  omission  of  much  which  freights  many  treatises 
heavily  without  bringing  cor  responding  instruction 
to  the  reader.  Dr.  Attfield  wiites  for  students,  and 
primarily  for  medical  students;  he  always  has  an 
eye  to  the  pharmacopoeia  and  its  officinal  prepara- 
tions; and  he  is  continually  putting  the  matter  in 
the  text  so  that  it  responds  to  the  questions  with 
which  each  section  is  provided.  Thus  the  student 
learns  easily,  and  can  always  refresh  and  test  his 
knowledge. — Mud  and Hurg.  Reporter,  Apriil9,'79. 

We  noticed  only  about  two  vears  and  a  half  ago 
the  publication  of  the  preceding  edidon,  and  re- 
marked npon  the  exceptionally  valuable  cha  racter 


This  very  popular  and  meritorious  work  has  i  of  the  work.  The  work  now  iacludes  the  whole  of 
now  reached  its  eighth  edition,  which  fact  speaks  \  the  chemistry  of  the  pharmacopoeia  of  the  Dnited 
in  the  highest  terms  in  commendation  of  its  excel-  '  States,  Great  Britain,  and  India. — ^em  Reraediea, 
Ijnce.     It  has  now  become  the  principal  text-book  i  May,  1879. 


G 


REENE  {WILLIAM  E.),  M.D., 

Demonstrator  of  Chemistry  in  Med.  Dept.,  Univ.  of  Penna. 

A  MANUAL  OF  MEDICAL  CHEMISTRY.    For  the  Use  of  Students. 

Based  upon  Bowman's  Medical  Chemistry.  In  one  royal  12mo.  volume  of  312  pages. 
With  illustrations.     Cloth,  $1  75.     {Now  Ready.) 

It  is  well  written,  and  gives  the  latest  views  on  I  The  little  work  before  us  is  one  which  we  think 
vital  chemistry,  a  subject  with  which  most  physi-  I  will  be  studied  with  pleasure  and  profit.  The  de- 
ciaas  are  not  sufficiently  familiar.  To  those  who  scrintions,  though-brief,  are  clear,  and  in  most  cases 
may  wish  to  improve  their  knowledge  in  that  direc  i  sufficient  for  the  purpose  This  book  will,  in  nearly 
tion,  we  can  heartily  recommend  this  work  asbeing  all  case?,  meet  general  approval. — An.  Joum.  of 
worthy  ufacarefnlperusal. — Phila .  Med.  and  Siirg .  ,  Pharmacy,  April,  1880. 
iJe^oj-te?-,  April  24,  1S80.  I 

flLASSEN  {ALEXANDER), 

^  Professor  in  the  Royal  Polytechnic  School,  Aixla-Chapelle. 

ELEMENTARY    QUANTITATIVE    ANALYSIS.     Translated  with 

notes  and  additions  by  Edgar  F.  Smith,  Ph.D.,  Assistant  Prof,  of  Chemistry  in  the 
Towne  Scientific  School,  Univ.  of  Penna.  In  one  handsome  royal  12mo.  volume,  of  324 
pages,  with  illustrations ;  cloth,  $2  00.     (Just  Ready.) 

advancing  to  the  analysis  of  minerals  and  such  pro- 
ducts as  are  met  with  in  applied  chemistry.  It  is 
an  indispensable  book  for  students  in  chemistry.— » 


It  is  probably  the  best  manual  of  an  elementary 
nature  extant,  insomuch  as  its  methods  are  the  best. 
It  teaches  by  examples,  commencing  with  single 
determinations,  followed  by  separations,  and  theu 


Boston  Journ.  of  Ghemistry,  Oct.  1878. 


riALLOWAY  {ROBERT),  F.C.S., 

^~^  Prof  of  Applied  Chemistry  in  the  Royal  College  of  Science  for  Ireland,  etc. 

A  MANUAL  OF  QUALITATIVE  ANALYSIS.  From  the  Fifth  Lon- 
don Edition.  In  one  neat  royal  12mo.  volume,  with  illustrations  ;  cloth,  $2  75.  (Lately 
Issued.) 

PEMSEN{IRA),  M.D.,  Ph.D., 

Professor  of  Oherai,itry  in  the  Johns  Hopkins  University,  Baltimore. 

PRINCIPLESOF  THEORETICAL  CHKMISTRY,  with  special  reference 

to  the  Constitution  of  Chemical  Compounds.   In  one  handsome  royal  12mo.  vol.  of  over 
232  pages:  cloth,  $1  50.     (Just  Issued.) 


BOWMAN'S  INTRODUCTION  TO  PRACTICAL 
CHEMISTRY,  INCLUDING  ANALYSIS.  Sixth 
Araer.can,  from  the  sixth  and  revised  London  edi- 
tion With  numerous  illustrations.  In  one  neat 
vol.,  royal  12mo.,  cloth,  |2  25. 


WOHLER  AND  FITTIG'S  OUTLINES  OF  ORGANIC 
CHEMJSTRY.  Translated  with  additionsfrom  the 
Eighth  German  Edition.  By  Ira  Rem.sen.  M  D., 
Ph  D,,  Prof  ofUhemisiry  nnd  Physics  in  Williams 
College,  Mass.  In  one  volume,  royal  12mo.  of  550 
pp.,  cloth,  $3. 


10 


Henry  C.  Lea's  Son  &  Co.'s  Publications — ( Chemistry'). 


mWNES  {GEORGE),  Ph.D. 
^   A  MANUAL  OF  ELEMENTARY  CHEMISTRY;  Theoretical  and 

Practical.  Revised  and  corrected  by  Henby  Watts,  B.  A. ,  F.R.S.,  author  of  "A  Diction- 
ary of  Chemistry,"  etc.  With  a  colored  plate,  and  one  hundred  and  seventy-seven  illus- 
trations. A  new  American,  from  th(  twelfth  and  enlarged  London  edition.  Edited  by 
Robert  Bridges,  M.D.  In  one  large  royal  12mo.  volume,  of  over  1000  pages; 
cloth,  $2  75  ;  leather,  $3  25.     (Just  Issued.) 


This  work,  inorganic  and  orgauic,is  complete  in 
one  convenient  volume.  In  its  earliest  editions  it 
was  fully  up  to  the  latest  advancements  and  tlieo- 
riee  of  tliat  lime.  In  its  present  form,  it  presents, 
in  a  remarkably  convenieut  and  satisfactory  man- 
ner, the  principles  and  leading  facts  of  the  chemistry 
of  to-day.  Concerning  the  manner  in  which  the 
various  subjects  are  treated,  much  deserves  to  be 
said,  and  mostly,  too,  in  praii-e  of  the  book.  A  re- 
view of  such  a  work  ai-  Fownes's  Ohemi-itry  within 
the  limits  of  a  book-notice  fir  a  medical  weekly  is 
simply  out  of  the  question. — Gi7icinnnti  Lancet  and 
Clinic,  DfC.  14, 1878. 

When  we  state  that,  in  our  opinion,  (he  present 
edition  sustains  in  every  respect  tbe  high  reputation 
which  its  predecesso'-s  have  acquired  and  eujoyed, 
we  express  therewith  our  full  belief  in  its  intrinsic 
value  as  a  text-book  and  work  of  reference. — Am. 
Journ.  of  Pharm.,  Aug.  1878. 

The  conscientious  care  which  has  been  bestowed 
upon  it  by  the  American  and  English  editors  renders 
it  still,  perhaps,  the  best  book  for  the  student  and  the 
practitioner  who  would  keep  alive  the  acquisitions 
of  his  student  days.    It  has, indeed,  reached  a  some- 


what formidable  magnitude  with  its  more  than  a 
thoufand  pages,  but  with  less  than  this  no  fair  repre- 
sentation of  chemistry  as  it  now  is  can  be  given.  The 
type  is  small  but  very  clear,  and  the  sections  are  very 
lucidly  arranged  to  facilitate  study  and  reference.— 
Med.  and  Sttrg.  Seporter,  Aug  3,  1878. 

The  work  is  too  well  known  to  American  students 
to  need  any  extended  notice;  suffice  it  to  say  that 
the  revi.-ion  by  the  Koglish  editor  has  been  faithfully 
done,  and  thai  l-'rofessor  Bridges  has  added  some 
fresh  and  valuable  matter,  espacially  in  the  inor- 
ganic chemistry.  The  book  has  always  been  a  fa- 
vorite in  this  country,  and  in  its  new  shape  bids 
fair  to  retain  all  its  former  prestige. — Boston  four, 
of  Chemistry,  Aug.  1878. 

It  will  be  entirely  unnecessary  for  us  to  make  any 
remarks  relating  to  the  general  characterof  Fownes' 
Manual.  For  over  twenty  years  it  has  held  the  fore- 
most place  as  a  text-book,  and  the  elaborate  and 
thorough  revisions  which  have  been  made  from  time 
to  time  leave  lit  tie  chance  for  any  wide  awake  rival  to 
step  before  it. — Canadian  Pharm.  Jour.,  Aug.  1878. 

^8  a  manual  of  chemistry  it  is  without  a  superior 
in  the  language. — Md.  Med.  Jour.,  Aug.  1878. 


B 


LOXAM  iC.L.), 

Profe.tsor  of  Oheraistry  in  King'' s  College,  London. 

CHEMISTRY,  INORGANIC  AND  ORGANIC.  From  the  Second  Lon- 
don Edition.  In  one  very  handsome  octavo  volume,  of  700  pages,  with  about  300  illus- 
trations.    Cloth,  $4  00;  leather,  $5  00.     {Lately  Issued.) 


We  have  in  this  work  a  completeand  most  excel- 
lent text-book  for  the  use  of  schools,  and  can  heari- 
ily  recommend  it  as  such. — Boston  Med.  and  Sitrg. 
Journ.,  May  28,  1874. 

The  above  is  the  titleof  a  work  which  we  can  most 
coascientiously  recommend  to  students  of  chemis- 
try. It  is  as  easy  as  a  work  on  chemistry  could  be 
made,  at  thesame  lime  that  it  preseutsa  full  account 
of thatscience  as  it  now  stands.  We  have  spoken 
of  the  work  as  admirably  adapted  to  the  wants  of 
students  ;  it  is  quite  as  well  suited  to  the  require- 
ments of  practitioners  who  wish  to  review  their 
chemistry,  or  have  occasion  to  refresh  their  memo- 
ries on  any  point  relating  to  it.  In  a  word,  it  is  a 
book  to  be  read  by  all  tvho  wish  to  know  what  is 
the  chemistry  of  the  presentday. — American  Prae- 
titioner, Soy. 1873. 


It  would  be  difficult  for  a  practical  chemist  and 
teacher  to  find  any  material  fault  with  this  most  ad- 
mirable treatise,  '  The  author  has  given  us  almost  a 
c}  clopjedia  within  thelimitsofaconvenient  volume, 
and  has  done  so  without  penning  ihe  useless  para- 
graphs too  commonly  making  up  a  great  part  of  the 
bulk  of  many  cumbrous  works.  The  progressive 
scientist  is  not  disappointed  when  he  looks  for  tha 
record  of  new  and  valuable  processes  and  discover- 
ies, while  the  cautious  conservative  does  not  find  its 
pages-monopolized  by  uncertain  theories  and  specu- 
lations. A  peculiar  point  of  excellence  is  the  crys- 
tallized foim  of  expression  in  which  great  truths  are 
expressed  iu  very  short  paragraphs.  One  is  surprised 
at  the  brief  space  allotted  to  an  important  topic,  and 
yet,  after  reading  it,  he  feels  that  little,  if  any  more 
should  have  been  said.  Altogether,  it  is  seldom  yoa 
see  a  text-book  so  nearly  faultless.  —  Cincinnati 
Lancet,  Nov.  1873. 


flLOWES  (FRANK),  D.Sc.  London. 

^  Senior  Science-Master  at  the  High  School,  Newcastle-ii'nder-Lyme,etc. 

AN  ELEMENTARY  TREATISE  ON  PRACTICAL  CHEMISTRY 

AND  QUALITATIVE  INORGANIC  ANALYSIS.  Specially  adapted  for  Use  in  the 
Lahoratories  of  Schools  and  Colleges  and  by  Beginners.  Second  American  from  the 
Third  and  Revised  English  Edition.  In  one  very  handsome  royal  12mo.  volume  of 
372  pages,  with  47  illustrations.     Cloth,  $2  50.      (just  Ready.) 

A  few  notices  of  the  previous  edition  are  appended. 

It  is  short,  concise,  and  eminently  practical.  We  i  are  so  simple,  andj-et  concise,  as  to  he  interesting 
therefore  heartily  commendit  to  students,  and  espe- 


cially to  those  who  are  obliged  to  dispense  with  a 
master.  Of  course,  a  teacher  is  in  every  way  desi- 
rable, but  a  good  degree  of  technical  ."kill and  prac- 
tical knowledge  can  be  attained  with  no  other 
instructor  than  the  very  valuable  handbook  now 
under  consideration. — St.  Louis  Clin.  Record,  Oct. 
1877. 

The  work  is  so  written  and  arranged  that  it  can  he 
comprehended  by  the  student  without  a  teacher,  and 
the  descriptions  and  directions  forthe  varftus  work 


and  intelligible.  The  work  is  unincumbered  with 
theoretical  deductions,  dealing  wholly  with  the 
practical  matter,  which  it  is  the  aim  of  this  compre- 
hensive text-book  to  impart.  The  accuracy  of  the 
analytical  methods  are  vouched  for  from  the  fact 
that  they  have  all  been  worked  through  by  tbe 
author  and  the  members  of  his  class,  from  the 
printed  text.  We  can  heartily  recommend  the  work 
to  the  student  of  chemistry  as  being  a  reliable  and 
comprehensive  one.— Druggists'  Advertiser,  Oct. 
15,  1877. 


KNAPP'S  TECHNOLOGY;  or  Chemistry  Applied  to 
the  Arts  and  to  Manufactures.  With  American 
additions  by  Prof.  Walter  K.  Johnson.    In  two  i 


very  handsome  octavo  volumes,  with  500  wood 
engravings,  cloth,  $6  00. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Phar.^  Mai.  3fed.,etc.).    11 


pARRISH  [EDWARD), 

Late  Professor  of  Materia  Medica  in  the  Philadelphia  College  of  Pharmacy. 

A  TREATISE  ON  PHARMACY.    Designed  as  a  Text-Book  for  the 

Student,  and  as  a  Guide  for  the  Physician  and  Pharmaceutist.    'V^th  many  Formulae  anJ 

Prescriptions.     Fourth  Edition,  thoroughly  revised,  by  Thomas  S.  Wiegand.      In  one 

handsome  octavo  volume  of  977  pages,  with  280  illustrations  ;  cloth,  $5  60  ;  leather,  $6  60; 

half  Russia,  $7.     (Lately  Issued.) 

Of  T)r.  Panish's  great  work  on  jiharraaoy  it  only  I  the  work,  not  only  to  pharmaciBts,  but  also  to  the 

remains  to  be  said  thatthe  editor  has  actuajpliwhed  j  multitude  of  medical  practiiioners  who  are  obliged 

his  work  so  well  as  to  maintain,  in  this  fourth  edi- 1  to  compound  their  own  medici  nes.    It  will  ever  bold 

tion    the  high  standard  of  excellence  which  it  bad    an  honored  place  on  our  own  bookshelves. — Dublin 

""  '       .  -  -  i:        .  ._    ^    Med.  Pre.te and  Gircular,  Aug.  12,,  ibH. 


attained  in  previous  editions,  under  the  editorship  of 
its  accomplished  author.  This  has  not  been  accom- 
plished withoul  much  labor, and  many  additions  and 
improvements,  involving  changes  in  the  arrange- 
mentof  the  several  parts  of  the  work,  and  the  addi- 
tion of  much  new  matter.  With  the  modifications 
thus  effected  it  constitutes,  as  now  presented,  a  com- 
pendium of  the  science  and  art  indispensable  to  the 
pharmacist,  and  of  the  utmost  value  to  every 
practilioner  of  medicine  desirous  of  familiarizing 
himself  with  the  pharmaceutical  preparation  of  the 
articles  which  he  prescribes  forhispatients. — Ghi- 
eago  Med.  Journ. ,Jxily,lS7i. 

The  work  is  eminently  praitical,  and  has  the  rare 
merit  of  being  readable  ^nd  interesting,  while  it  pre- 
serves astrictly  scienliflccbaracter.  The  whole  work 


We  expressed  our  opinion  of  a  former  edition  in 
terms  of  unqualified  praise,  and  we  are  in  no  mood 
to  detract  from  that  opinion  in  reference  to  the  pre- 
sent edition,  the  preparation  of  which  has  fallen  in  to 
competent  hands.  It  is  a  book  with  which  no  pharma- 
cist can  dispense,  and  from  which  no  physician  can 
fail  to  derive  much  information  of  value  to  him  in 
practice. — Pacific  Med.  and  Surg .  Journ. ,  June, '74. 

Perhaps  one,  if  not  the  most  important  book  upon 
pharmacy  which  has  appeared  in  the  English  lan- 
guage has  emanated  from  the  transatlantic  press. 
"Parrish's  Pharmacy"  is  a  well-known  work  on  this 
side  of  the  water,  and  the  fact  shows  us  that  a  really 
useful  work  neverbecomes  merely  local  in  its  fame. 


reflects  the  greatest  credit  on  author,  editor  andpnb  j  Thanks  to  the  judicious  editing  of  Mr.  Wiegand,  the 
lisher.  It  will  convey  some  idea  of  the  liberality  which  posthumous  edition  of  "Parrish"  has  been  saved  to 
hasbeenbestowed  upon  itsproduction  when  we  men-i  the  public  with  all  the  mature  experience  of  its  au- 
tion  that  there  are  no  less  than  2S0  carefully  executed  '  thor,  and  perhaps  none  the  worse  for  a  dash  of  new 
iUustratioas.  In  conclusion,  we  heartily  recommend   blood. — Lond.  Pharm.  Journal,  Oct.  17, 1874. 

QRIFFITH  {ROBERT  E.),  M.D. 

A  UNIVERSAL  FORMULARY,  Containing  the  Methods  of  Prepar- 

ing  and  Administering  Officinal  and  other  Medicines.  The  whole  adapted  to  Physiciars  and 
Pharmaceutists.  Third  edition,  thoroughly  revised,  with  numerous  additions,  bj  John  M. 
Maisch,  Professorof  Materia  Medica  in  the  Philadelphia  College  of  Pharmacy.  In  one  large 
andhandsome  octavo  volume  of  about80flpp.,  cL,  $450  ;  leather,  $5  50.  (Lately  Issued.) 
To  the  druggist  a  good  formulary  is  simply  indis- 
pensable, and  perhaps  no  formulary  has  been  more 
extensively  used  than  the  well-known  work  before 


ns.  Many  physicians  have  to  officiate,  also,  as  drug- 
gists. This  is  true  especially  of  the  country  physi- 
cian, and  a  work  which  shall  teach  him  the  means 
by  which  to  administer  or  combine  his  remedies  in 
the  most  efficacious  and  pleasant  manner,  will  al- 
ways hold  its  place  upon  his  shelf.  A  formulary  of 
this  kind  is  of  benefit  also  to  the  city  physician  in 
largest  practice. — Qincinnati  'Clinic,  Feb.  21,  1S74. 


A  more  complete  formulary  than  it  is  in  its  pres- 
ent form  the  pharmacist  or  physician  could  hardly 
desire.  To  the  first  some  such  work  is  indispensa- 
ble, and  it  is  hardly  les.a  essential  to  the  practitioner 
who  compounds  his  own  medicines.  Much  of  what 
is  contained  in  the  introduction  ought  to  be  com- 
mitted to  memory  by  every  student  of  medicine. 
As  a  help  to  physicians  it  will  be  found  invaluable, 
and  doubtless  will  make  its  way  into  libraries  not 
already  supplied  with  a  standard  work  of  the  kind  . 
—  The  American  Practitioner ,\jO\i.isv\\\e,  July, '74. 


F 


fARQUHARSON  (ROBERT),  3I.D., 

Leeturer  on  3Iateria  Median- at  fit.  Mary'' s  Hospital  Medical  School. 

A  GUIDE  TO  THERAPEUTICS  AND  MATERIA  MEDICA. 


Se- 


cond  American  edition,  revised  by  the 
Pharmacopoeia.  By  Frank  Woodbury 
pages:  cloth,  $2.25.     (Just  Beady.) 

The  appearance  of  a  new  edition  of  this  conve- 
nient and  handy  book  in  less  than  two  years  may 
certainly  be  taken  as  an  indication  of  its  useful- 
ness. It's  con'-enient  arrangement,  and  its  terse- 
ness, and,  at  the  same  time,  comoleteness  of  the 
information  given,  make  it  a  handy  book  of  refer- 
ence.— Am.  Journ.  of  Pharmacy,  June,  1S79. 

This  work  contains  in  moderate  compass  such 
well-digested  facts  concerning  the  physiological 
and  therapeutical  action  of  remedies  as  are  reason- 
ably established  up  to  the  present  time.  By  a  con- 
venient arrangement  the  corresponding  effects  of 
each  article  in  health  and  disease  are  presented  in 
parallel  columns,  not  only  rendering  reference 
easier,  but  also  impressing  the  facts  more  strongly 
upon  the  mind  of  the  reader.  The  book  has  been 
adapted  to  the  wants  of  the  American  student,  and 


Author.     Enlarged  and  adapted  to  the  U.  S. 
,  M.D.     In  one  neat  royal  12mo.  volume  of  498 

copious  notes  have  been  introduced,  embodying  the 
latest  revision  of  the  Pharmacopoeia,  together  with 
the  antidotes  to  the  more  promiuent  poisons,  and 
such  of  the  newer  remedial  agents  as  seemed  neces- 
sary f.o  the  completeness  of  the  work.  Tables  of 
weights  and  measures,  and  a  good  alphabetical  in- 
dex end  the  volume. — Druggists^  Circular  and 
Chemical  Gazette,  June,  1879. 

It  is  a  pleasure  to  think  that  the  rapidity  with 
which  a  second  edition  is  demanded  may  be  taken 
as  an  indication  thatthe  sense  of  appreciation  of  the 
value  of  reliable  information  regarding  the  use  of 
remedies  is  notentirely  overwhelmed  in  the  cultiva- 
tion of  pathological  studies,  characteristic  of  the  pre- 
sent day.  This  work  certainly  merits  the  success  it 
has  80  quickly  achieved. — New  Remedies,  July,  '79. 


CHRISTISON'S  DISPENSATORY.  With  copious  ad- 
ditions, and  21.3  large  wood  engravings.  By  R. 
EoLESFiELD  GRIFFITH,  M.D.  One  vol.  8vo.,  pp. 
1000,  cloth,  *4  00. 


CARPENTER'S   PRIZE  ESSAY  ON  THE  USE   OP 

ALCOHOX.IC  LiQtTORS  IJf  HEALTH  AND  DISEASE.    NeW 

edition,  with  a  Preface  by  D.  P.  Condte,  M.D.,  and 
explanationsof  scientificwords.  In  oneneatl2mo. 
volume,  pp.  178,  cloth,  60  cents. 


12  Henry  C.  Lea's  Son  &  Co.'s  Publications — (Mat.  3Ied.  and  Therap.). 
fJTILLE  [ALFRED),  M.D.,  LL.D.,  and  JXfAlSCH  [JOHN  M.).  Ph.D., 

f^        Prof,  of  Theory  and  Practice,  of  Medicine  J-f-L        Prof,  of  Mat.  Med.  and  Bot  in  PkiTn. 

and  of  Clinical  Med.  in  Univ.  of  Pa.  Coll.  Pharmacy,  Seey.  to  the  American 

Pharmaceutical  Association. 

THE  NATIONAL  DISPENSATOEY :  Containing  the  Natural  History, 

Chemistry,  Pharmacy,  Actions  and  Uses,  of  Medicines,  including  those  recognized  in 
the  Pharmacopoeias  of  the  United  Stiites,  Great  Britain,  and  Germany,  with  numer- 
ous references  to  the  French  Codez.  Second  edition,  thoroughly  revised,  ■with  numerous 
additions.  In  one  very  handsome  octavo  volume  of  1692  pages, with  2.39  illustrations. 
Extra  cloth,  $6  75  ;  leather,  raised  bands,  $7  60  ;  half  Russia,  raised  bands  and  open 
back,  $8  25.     {Now  Ready.) 

Preface  to  the  Second  Edition. 

The  demand  which  has  exhausted  in  a  few  months  an  unusually  large  edition  of  *he  N'ational 
Dispensatory  is  doubly  gratifying  to  the  authors,  as  showing  that  t*iey  were  correct  in  thinking 
that  the  want  of  such  a  work  was  felt  by  the  medical  and  pharmaceutical  professinns.  and  that 
their  efforts  to  supply  that  want  have  been  acceptable.  This  appreciation  of  their  Inbors  has 
stimulated  them  in  the  revision  to  render  the  volume  more  worthy  of  the  very  marked  favor 
with  which  it  has  been  received.  The  first  edition  of  a  work  of  pueh  magnitude  must  necessarily 
be  more  or  less  imperfect ;  and  though  but  litt'e  that  is  new  and  important  has  been  brought 
to  light  in  the  short  interval  since  its  publication,  yet  the  length  of  time  during  which  it  was 
passing  through  the  press  rendered  the  earlier  portions  more  in  arrears  than  the  la'er.  The 
opportunity  for  a  revision  has  enabled  the  authors  to  scrutinize  the  work  as  a  whole,  and  to 
introduce  alterations  and  additions  wherevef  there  has  seemed  to  be  occasion  for  improve- 
ment or  greater  completeness.  The  principal  changes  to  be  noted  are  the  introduction  of  seve- 
ral drugs  under  separate  headings,  and  of  a  large  number  of  drugs,  chemicals,  and  pharma- 
ceutical preparations  classified  as  allied  drugs  and  preparations  under  the  heading  of  more 
important  or  better  known  articles :  these  additions  comprise  in  part  nearly  the  entire  German 
Pharmacopoeia  and  numerous  articles  from  the  French  Codex.  All  new  investieation?  which 
came  to  the  authors'  notice  up  to  the  time  of  publication  have  received  due  corsideration. 

The  series  of  illustrations  has  undergone  a  corresponding  thorough  revision.  A  number  have 
been  added,  and  still  more  have  been  substituted  for  such  as  were  deemed  less  satisfactory. 

The  new  matter  embraced  in  the  text  is  equal  to  nearly  one  hundred  pages  of  the  first  edition. 
Considerable  as  are  these  changes  as  a  whole,  they  have  been  accommodated  by  an  enlargement 
of  the  page  without  increasing  unduly  the  size  of  the  volume. 

While  numerous  additions  have  been  made  to  the  sections  which  relate  to  the  physiological 
action  of  medicines  and  their  use  in  the  treatment  of  disease,  great  care  has  been  taken  to 
make  them  as  concise  as  was  possible  without  rendering  them  incomplete  or  obscure.  The 
doses  have  been  expressed  in  the  terms  both  of  troy  weight  and  of  the  metrical  system,  for  the 
purpose  of  mak'ng  those  who  employ  the  Dispensatory  familiar  w.th  the  latter,  and  paving  the 
way  for  its  introduction  into  general  use. 

The  Therapeutical  Index  has  been  extended  by  about  2250  new  references,  making  the  total 
number  in  the  present  edition  ab^^ut  6000. 

The  articles  there  enumerated  as  remedies  for  particular  diseases  are  not  only  those  which, 
in  the  authors'  opinion,  are  curative,  or  even  beneficial,  but  those  also  which  have  at  anytime 
been  employed  on  the  ground  of  popular  belief  or  professional  authority.  It  is  often  of  as 
much  consequence  to  be  acquainted  with  the  wnrthlessness  of  certain  medicines  or  with  the 
narrow  limits  of  their  power,  as  to  know  the  well  attested  virtues  of  others  and  the  conditions 
under  which  they  are  displayed.  An  additional  value  possessed  by  such  an  Index  is,  that  it 
contains  the  elements  of  a  natural  classification  of  medicines,  founded  upon  an  analysis  of  the 
results  of  experience,  which  is  the  only  safe  guide  in  the  treatment  of  disease. 

This  evidence  of  success,  seldom  paralleled,  j  keep  the  work  up  to  the  time. — ^ew  Remedies,  Noy. 
shows  clearly  how  well  the  anthers  have  met  the  I  1879. 


existing  needs  of  the  pharmaceutical  and  medical 
professions.  Gratifying  as  it  must  be  to  them,  they 
have  embraced  the  opportunity  offered  for  a  thor- 
ough levision  of  the  whole  work,  striving  to  era- 
brace  within  it  all  that  might  have  been  omitted  in 
the  former  edition,  and  all  that  has  newly  appeared 
of  sufficient  importance  during  the  time  of  its  col- 
laboration, and  the  short  interval  elapsed  since  the 
previous  publication.  After  having  gone  carefully 
through  the  volume  we  must  admit  that  the  authors 
have  labored  faithfully,  and  with  success,  in  main- 
taining the  high  character  of  their  work  as  a  com- 
pendium meeting  the  requirements  of  the  day,  to 
which  one  can  safely  turn  in  quest  of  the  latest  in- 
formation concerning  everything  worthy  of  notice  in 
connection  with  Pharmacy,  Materia  Medica,  and 
Therapeutics. — Am.  Joiir.  of  Pharraacy,  Nov.  1879. 
It  is  with  great  pleasure  that  we  announce  to  our 
readers  the  appearance  of  a  second  edition  of  the 
National  Dispensatory.  The  total  exhaustion  of  the 
first  edition  in  the  short  space  of  six  months,  is  a 
sufficient  testimony  to  the  value  placed  upon  the 
work  by  the  profession.  It  appears  that  the  rapid 
sale  of  the  first  edition  must  have  induced  both  the 
editors  and  the  publisher  to  make  preparations  for 
a  new  edition  immediately  after  the  first  had  been 
issued,  for  we  find  a  large  amount  of  new  matter 
added  and  a  good  deal  of  the  previous  text  altered 
»ad  improvfid.  which  proves  that  the  authors  do  not 
intend  to  let  the  grass  grow  under  their  feet,  but  to 


This  is  a  gr?at  work  by  two  of  the  ablest  writers  ou 
materia  medioa  in  Amerifa  The  authors  h-  ve  pro- 
duced a  work  which,  for  accuracy  and  comprehen.«ivt- 
ness,  is  un.«:urpasped  by  any  work  on  ths  subject.  There 
is  no  book  in  the  Knglish  language  vihich  contains  so 
much  valuable  information  on  the  various  articles  of 
the  materia  medica.  The  work  has  cost  the  authors 
years  of  laborious  study,  but  they  have  succeeded  in 
producing  a  dispensatory  which  is  not  only  national, 
but  will  be  a  lasting  memorial  of  the  learning  and 
ability  of  the  authors  who  produced  it. — Edinburgh 
Medica!  Journal,  Nov.  1879. 

It  is  by  far  more  international  or  universal  than 
any  other  book  of  the  kind  in  our  language,  and 
more  comprehensive  in  every  sense. —  Pacifie  Med. 
and  S^irg.  -/own.,  Oct.  1879. 

The  National  Dispensatory  is  beyond  dispute  the 
very  best  authority.  It  is  throughout  complete  in 
all  the  necessary  details,  clear  a,nd  lucid  in  its  ex- 
planations, and  replete  with  references  to  the  most 
recent  writings,  where  further  particulars  can  be 
obtained,  if  desired.  Its  value  is  greatly  enhanced 
by  the  extensive  indices — a  general  index  of  materia 
medica,  etc.,  and  also  an  index  of  therapeotics  It 
would  be  a  work  of  supererogation  to  say  more  about 
this  well-known  work.  No  practisiug  physician  can 
afford  to  be  without  the  National  Dispensatory.— 
Canada  Med.  and  Surg.  Journ.,  Feb   1880. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Mat.  Med.^Therap.,  etc.).   13 


^TILLE  [ALFRED),  M.D., 

Prufej-.Hor  of  Theory  and  Practice  of  Medicine  in  the  University  of  Penna. 

THERAPEUTICS  AND  MATERIA  MEDICA;  a  Systematic  Treati-e 

on  the  Action  and  Uses  of  Medicinal  Agents,  including  their  Description  and  History 
Fourth  edition,  revised  and  enlarged.  In  two  large  and  hiindsome  8vo.  vols,  of  about  2000 
pnges.     Cloth,  $10;  leather,  $12;  half  Russia,  $13.     (Lately  Issued.) 


It  is  unuecessaiy  to  do  rauch  moi'e  tlmo  to  an- 
nouuce  the  appearnuce  of  tlie  f'oiii-th  edition  of  this 
wall  kiiowa  mid  exclleiii  work. — Brit,  and  For. 
Med.-Ohir.  Rfimew,<)ct  Ks75, 

For  all  who  desire  a  complete  work  on  therapeu- 
tics -lud  materia  inedica  for  refereuce,  in  case^- iu- 
vulviug  medico-legal  qiie.stioas,  as  well  as  foiia- 
formal  ion  CO  nee  ruing  re  medial  agents,  l)r.  Still6'f  i.s 
"v'lr  fxielleneey  the  work  Beiugoui  of  print,  by 
the  exhaustion  of  former  editions,  t  he  author  has  laid 
the  profession  under  renewed  obligations,  Vjy  the 
careful  revision,  important  additions,  and  timely  re- 
issuing a  work  not  exactly  supplemented  by  any 
other  in  the  English  language,  if  in  any  language. 
The  mechanical  execution  handsomely  sustains  the 
well-known  skill  and  good  taste  or  ihe  publisher. — 
St.  l/oni.t  Med.  and  Hnrp.  -foHrntil,  Dec   1874. 

From  the  publication  of  the  first  edition  "Still^'s 
Thera.peutic8"  has  been  one  of  the  classics;  its  ab- 
sence from  our  libraries  would  create  a  vacniira 
which  could  be  filled  by  no  other  work  in  the  lan- 
guage, and  it.s  presence  supplies,  in  the  two  volumes 


of  I  he  present  ediliun,  a  whole  cyclopaedia  of  thera- 
peutics.—  dhic'igo  Medici  ■/ourna I,  Feb.  IST.j. 

The  rapid  exhaustion  ofthreeeditioni-and  the  uni- 
versal favor  wilh  which  the  work  has  been  received 
by  the  medical  profession,  are  sufficient  proof  of  ill" 
excellence  as  a  repnrtory  of  practical  and  useful  in- 
formation for  the  physician.  The  edition  before  U8 
fully  sustains  this  verdict, as  the  work  hasbeen  care- 
fully revised  and  in  some  p'irtions  rewritten,  bring- 
ing it  up  to  the  present  time  by  the  admission  of 
chloral  and  croton  chloral  nitrite  of  amyl,  bicblu- 
ride  of  mnthyleue,  melhylic  ether,  lithium  com- 
pounds, gelseminum,  and  other  remedies. — Ant 
■ToTrn   of  Pharma<:ii,  Feb.  1S7.5. 

We  can  hardly  admit  that  it  has  a  rival  in  tbe 
multitnde  of  its  citati'ins  and  tbe  fulness  of  its  re- 
search into  clinical  histories,  and  we  must  assign  it 
a  place  in  the  physician's  library;  not,  ind'^e*,  as 
fully  ri>pre~enting  the  present  slate  of  knowledge  in 
pharmacodynamics,  but  as  by  far  the  most  complete 
treatise  upon  the  clinical  and  practical  side  of  the 
question. — Bonton  Mtd.  and  Surg.  Journal,  Nov.  fi. 
1R74. 


nORNIL  (F.), 

^        Prof,  in  the  Fa 


PANVIER  (L.), 

-*■  *^         Prof  in  the  Colle 


AND 

Faculty  of  Med  ,  Pnrin.  -«-  •^         Prof  in  the  College  of  France. 

MANUAL  OP  PATHOLOGICAL  HISTOLOGY.     Translated,  with 

Notes  and  Additions,  by  E.  0.  SHAKESPEAtiE,  M.D.,  Pathologist  and  Ophthalniic  Surgeon 
to  Pbilada.  Hospital,  Lecturer  on  Refrnction  and  Operative  Ophthnlmic  Surgery  in  Univ. 
of  Penrja.,  end  by  Hbnry  C.  Simrs    M  D.,  Denionstrut'  r  of  Pathological  Histology  in 
the    Univ.  of  Pa.     In  one  very  handsome  octavo  volume  of  over  700  pages,  with  over 
.350  illustrations-     Cloth,  S5  50;  leather,  $6  50;  half  Russia,  $7.      (Just  Read?/.) 
The  work  of  Cornil  and  Ran-'  ier  is  so  well  known  as  a  lucid  and  accurate  test-book  on  its 
important  subject,  that  no  apology  is  needed  in  presenting  a  translation  of  it  to  the  American 
profess'on.     It  is  only  necessary  to  say  that  the  labors  of  Drs.   Shakespeare  and  Simes  ha'^e 
been  by  no  me.'vns  confined  to  the  task  of  rendering  the  work  into  English.     As  it  appeared  in 
France,  in  successive  portions,  betwt  en  1868  and    1876,  a  part  of  it,  at  least,  was  somewhTt  in 
arrears  of  the  pr6,sent  state  of  science,  while  the  diffuseness  of  other  portions  ren-^ered  conden- 
sation desirable.     The  translators  have,  therefore,  sought  to  bring  the  work  up  to  the  day, 
and,  at  the  snme  time    to  reduce  it  in  size,  ai  far  as  practicable,  without  iait)airing  its  c   m- 
pleteness      These  changes  will   be  found  throughout  the  volume,  the  most  extensive  beine  in 
the  sections  devoted  to  Sarcoma,  Carcinima,  Tuberculosis,  the  Bloodvessels,  the  Mammae,  and 
the  classification  of  tumors      Corresponding  modifications  have  been  made  in  the  very  extt-n- 
sive  and  beautiful  series  of  illustrations,  and  every  cure  has  been  taken  in  the  typographical 
execution  to  render  it  one  of  the  most  attractive  volumes  which  have  issued  from  the  American 
press. 


We  have  aohesitation  in  cordia'ly  recommending 
tbe  English  translation  of  Cornil  &  Ranvier's  "  Pa- 
thological Histology"  as  the  best  work  of  the  kiid 
In  any  language,  and  as  giving  to  its  readers  a 
trustworthy  gnide  in  obtaining  a  broad  and  solid 
basis  for  the  appreciation  of  the  practical  bearings 
of  pathological  anatomy. — Ain.  Journ.  of  Med. 
Sciences,  April,  18S0. 

This  important  work,  in  its  American  dress,  is  a 
welcome  offering  to  all  students  of  tbe  subjects 
which  it  treats.  The  great  mass  of  material  is 
an'anged  naturally  and  comprehensively.  The 
classification  of  tumors  is  clear  and  full,  so  far  as 
the  subject  idmits  of  definition,  and  this  one  chap- 
ter is  worth  the  price  of  the  bork.  The  illustra- 
tions are  copious  and  well  chosen.  Without  the 
slightest  hesitation,  the  translators  deserve  honest 
thanks  for  placing  this  indispensable  work  in  the 
hands  of  American  students. — Phila.  Med.  Times, 
April  2t,  18S0 

This  "olume  we  cordially  commend  to  the  profes- 
sion. U  will  prove  a  valuable,  almost  necessary, 
addition  to  the  libraries  of  students  who  are  to  be 
physicians,  and  to  the  libraries  of  sludenls  who  are 
physicians.— ylmerico'/i  Practitioner,  June,  18S0. 


Their  book  is  not  a  collection  of  the  work  of  others, 
but  has  been  written  in  the  laboratory  beside  the 
microscope.  It  bears  the  marks  (.f  personal  knowl- 
edge and  investigation  upon  every  page,  controlled 
by  and  controlling  the  work  of  others.  ...  In 
short,  its  translation  has  made  it  the  best  work  in 
pathology  attainable  in  our  language,  one  that  every 
student  certainly  ought  to  have. — Archives  of  Med- 
icine, April,  ISSO. 

This  work,  in  the  original,  has  for  years  pjst 
occupied  a  prominent  place  in  the  library  of  French 
pathologists,  as  we  should  naturally  be  led  to  be- 
lieve from  the  reputation  of  the  distinguished  au- 
thors. Now  that  it  has  been  presented  to  tbe  Eng- 
lish student  for  tiie  first  time,  it  will  be  perused, 
with  unusual  interest.  The  illustrations  are  by  no 
means  the  least  valuable  part  of  the  work.  Indis-« 
pensable  as  they  are  to  any  work  of  this  natuie, 
in  the  work  before  us  the  artist  has  snccee^led  in 
producing  cuts  which  will  prove  unusually  valuable 
to  the  reader.  The  translation  is  well  done,  and 
gives  evidence  throughout  the  volume  that  it  was 
m^de  by  a  person  thoroughly  conversant  with  the 
subject.— iV.  T.  Med.  Gazette,  Feb.  28,  18S0. 


GLDGE'S  ATLAS  OP  PATHOLOGICAL  HISTOLOGY. 

Translated,  with  Notes  and  Additions,  by  Joseph  | 
tiFAor,  M.  D.    In  one  volume,  very  large  imperial 
quarto,  with   320  copper-plate  figures,  plain  and 
colored,  cloth.    $4  00.  I 


PAVY'.^  TREATISE  ON  THE  FUNCTION  OF  DI- 
GESTION: its  Disorders  aiid  their  Treatment. 
From  the  second  London  edition  In  one  band' 
some  volume,  small  ociavo,  cloth,  $2  00. 


14       Henry  C.  Lea's  Son  &  Co.'s  Publications — {Pathology^  etc.). 


PENWICK  (SAMUEL),  M.D., 

-*-  Ansistnnt  Phy.iictan  to  the  London  Hospitals 

THE  STUDENT'S  GUIDE  TO  MEDICAL  DIAGNOSIS.    From  the 

Third  Revised  and  Enlarged  English  Edition.     With  eighty-four  illustrations  on  wood. 
In  one  very  handsome  volume,  royal  12mo. ,  cloth,  $2  25.     {Just  Issued.) 

pREEN  ( T.  HENR Y),M.D., 

v^  Li'.cturp.r  on  Pathology  and  Morbid  Anatomy  at  Qharing-Cross  Hospital  Medical  School,  etc. 

PATHOLOGY  AND  MORBID  ANATOMY.    Third  American, from 

the  Fourth  Enlarged  and  Revised  English  Edition.     In  one  very  handsome  octavo  vol- 
ume of  .332  pages,  with  132  illustrations ;  cloth,  $2  25.     (Notv  Ready.) 

ciently  numerous,  and  usually  well  made.  In  the 
present  edition,  audi  new  matter  has  been  added  as^ 
was  necessary  to  embrace  the  later  results  in  patho- 
logical research.  No  doubt  it  will  continue  to  enjoy 
the  favor  it  has  received  at  the  hands  of  the  profes- 
sion.— Med.  and  Surg.  Reporter,  Feb.  1,  1879. 

For  practical,  ordinary  daily  use,  this  is  undoubt- 
edly the  best  treatise  that  is  offered  to  students  of 
pathology  and  morbid  anatomy. — Cincinnati  Lan- 
cet and  Glinic,  Feb.  8,  1879. 


This  is  unquestionably  one  of  the  best  manuals  on 
the  subject  of  pathology  and  morbid  anatomy  that 
can  be  placed  in  the  student's  hands,  and  we  are 
glad  to  see  it  kept  up  to  the  times  by  new  editions. 
Each  edition  is  carefully  revised  by  the  author,  with 
the  view  of  making  it  include  the  most  recent  ad- 
vance.s  in  patliobigy,  and  of  omitting  whatever  may 
have  become  obsolete.— iV.  Y.  Med.  Jotir.,  Feb.  1879. 

The  treatise  of  Dr.  Green  is  compact,  clearly  ex- 
press- d,  up  to  the  times,  and  popular  as  a  text-book, 
both  in  England  and  America.    The  cuts  are  suffi- 


J^'RISTO  WE  [JOHN  SYER),  M.D.,  F.R.C.P., 

Physician  and  Joint  Lecturer  on  Medicine,  St.  Thomas's  Hospital. 

TREATISE   ON   THE   PRACTICE   OF    MEDICINE.     Second 

American  edition,  revised  by  the  Author.  Edited,  with  Additions,  by  James  H.  Hutch- 
inson, M.D.,  Physicinn  to  the  Penna.  Hospital.  In  one  hand,=ome  octavo  volume  of 
nearly  1200  pages.      With  illustrations.     Cloth,  $5  00;    leather,  $6  00;  half  Russia, 


A 


$6  50.      {Now  Ready.) 

The  second  edition  of  tlii-s  excellent  work,  like  the 
first,  has  received  the  benefit  of  Dr.  Hutchinson's 
aanotations,  by  which  the  phases  of  disease  which 
are  peculiar  to  this  country  ure  indicated,  and  thus 
a  treatise  which  was  intended  for  British  practi- 
tioners and  students  is  made  more  practically  nstful 
on  this  side  of  the  water.  We  see  no  reason  to 
modify  the  high  opinion  previously  expressed  with 
rpgard  to  Dr.  Bristowe's  work,  except  by  adding 
our  appreciation  of  the  careful  labors  of  ttie  author 
in  following  the  lateral  growth  of  medical  science. 
Tho  chapter  on  diseases  of  the  skin  and  of  the  nerv- 
ous system,  with  a  new  one  on  insanity  compiled 
from  the  best  sources  outside  of  the  author's  own 
long  experience,  and  the  valuable  portion  relating 
10  general  pathology,  aid  greatly  in  completing  an 
exceptionally  good  book  for  purposes  of  reference 
and  ins  ru'.tion  — Boston  Medical  and  Surgical 
Journal,  February,  1880 

What  we  said  of  the  first  edition,  we  can,  with 
increased  emphasis,  repeat  concerning  this:  "  Every 
]iage  is  cha  racterized  by  the  ntteracces  of  a  thongbt- 
hil  man.  Wnat  has  been  said,  has  been  well  said, 
and  the  book  is  a  fair  reflex  of  all  that  is  certainly 


known  on  the  subjects  considered." — Ohio  Med. 
Recorder,  Jan.  7,  1880. 

The  views  of  the  author  are  expressed  with  preci- 
sion and  sufficient  promptness  to  impress  the  student 
with  the  weight  of  his  authority  ;  and  should  the 
medical  professor  ditfer  on  any  subject  from  his  doc- 
trine, he  will  need  to  find  strong  arguments  to  carry 
his  class  to  the  opposite  conclusion. — N.  0.  Med.  and 
Surg.  Journ.,  Feb.  1880. 

The  reader  will  find  every  conceivable  subject 
connected  with  the  practice  of  medicine  ably  pre- 
sented, in  a  style  at  once  clear,  interesting,  and  con- 
cise. The  additions  made  by  Dr.  Hatchinson  are 
appropriate  and  practical,  and  greatly  add  to  its 
usefulness  to  American  readers. — Buffalo  Med.  and 
Surg.  Jotirn.,  March,  18S0. 

We  regard  it  as  an  excellent  work  for  students  and 
for  practitioners.  It  is  clearly  written,  the  author's 
^tyle  is  attractive,  and  it  is  especially  to  be  com- 
mended for  its  excellent  exposition  of  the  pathol  'gy 
and  clinical  phenomena  of  disease. — St.  Louis  Glin. 
Record,  Feb.  1880. 


E 


ABERSHON  [S.  0.)  M.D. 

Senior  Physician  to  and  late  Lecturer  on  the  Principles  and  Practice  of  Medicine  at  Guy's 

Hospital,  etc. 

ON  THE  DISEASES  OF  THE  ABDOMEN,  COMPRISING  THOSE 

of  the  Stomach,  and  other  parts  of  the  Alimentary  Canal,  CEsophagus,  Caecum,  Intes- 
tines, and  Peritoneum.  Second  American,  from  the  third  enlarged  and  revised  Eng- 
lish edition.  AVith  illustrations.  In  one  handsome  octavo  volume  of  over  500  pages. 
Cloth,  $3  50.     (Now  Ready.) 

amended  by  the  author.  Several  new  chapters  have 
been  added,  bringing  the  work  fully  up  to  the  times, 
and  making  it  a  volume  of  interest  to  the  practi- 
tioner in  every  field  of  medicine  and  surgery.  Per- 
verted nutrition  is  in  gome  form  associated  with  all 
diseases  we  have  to  combat,  and  we  need  all  the 
light  that  can  be  obtained  on  a  subject  so  broad  and 
genera,!.  Dr.  Habershon's  work  is  one  that  every 
practitioner  should  read  and  study  for  himself. — 
N.  Y.  Med.  Journ  ,  April,  1879. 


This  valuable  treatise  on  diseases  of  the  stomach 
and  abdomen  has  been  ont  of  print  for  several  years, 
and  is  therefore  not  so  well  known  to  the  profession 
as  it  deserves  to  be.  It  will  be  found  a  cyclopsedia 
of  information,  systematically  arranged,  on  all  dis- 
eases of  the  alimentary  tract,  from  the  moath  to  the 
rectum.  A  fair  proportion  of  each  chapter  is  devoted 
to  symptoms,  pathology,  and  therapeutics.  The 
present  edition  is  fuller  than  former  ones  in  many 
particulars,  and  has  been  thoroughly  revised  and 


LA  ROCHE  ON  YELLOW  FEVER. considered  in  its 
Historical,  Pathological,  Etiological,  and  Thera- 
peutical Relations.  In  two  large  and  handsome 
octavo  volumes  of  nearly  I.tOO  pp. , cloth.    $7  OC. 

STOKES'  LECTURES  ON  FEVER  Edited  by  John 
William  Moore,  M.D.,  Assistant  Physician  to  the 
Cork  Street  Fever  Hospital.  In  one  neat  8vo 
volume,  cloth,  $2  00. 


HOLLAND'S  MEDICAL  NOTES  AND  REFLEC- 
TIONS.    1  vol.  8vo.,  pp.  500,  cloth.    $3.50. 

BARLOW'S  MANUAL  OF  THE  PRACTICE  OP 
MEDICINE.  With  Additions  by  D.  F.Condib. 
M   D.    T  vol.  8vo.,  pp.  600,  cloth.    S2  50. 

TODD'SCLINICALLECTURESoN  CERTAIN  ACUTE 
Diseases.  In  one  neat  octavo  volume,  of  320  pp., 
cloth.    $2  60. 


Henry  0.  Lea's  Son  &  Co.'s  Publications — (Practice  of  Medicine).  15 


PLINT  {AUSTIN),  M.D., 

■*■  Profasaor  of  t  he  Principles  and  Practice  of  Medicine  in  Bellevue  Med.  College,  N.  Y. 

A   TREATISE    ON   THE    PRINCIPLES  AND   PRACTICE    OF 

MEDICINE  ;  designed  for  the  use  of  Students  and  Practitioners  of  Medicine.  Fifth 
edition,  entirely  rewritten  and  munh  improved.  In  one  large  and  closely  printed  octiivo 
volume  of  1153  pp.  Cloth,  $5  60;  leather,  $6  50;  very  handsome  half  Russia,  raised 
bands,  $7.      (Just  Ready.) 

Extract  from  the  Author's  Preface. 

In  preparing  the  fifth  edition  of  this  treatise,  the  author  has  been  thoroughly  mindful  of  the 
progress  of  meilicine  since  the  publication  of  the  fourth  edition  in  1873.  Time  and  labor  have 
not  been  spared  in  the  endeavor  to  briQg  the  work  in  all  respects  up  to  the  present  state  of 
medical  knowledge. 

Dr.  William  H.  Welch,  Lecturer  on  Pathological  Histology  in  the  Bellevue  Hospital  Medical 
College,  has  contributed  in  Part  I.  the  first  seven  chapters,  embracing  the  general  pathology  of 
the  .solid  tissues  and  of  the  blood.  He  has  also  revised,  and  in  great  part  rewritten,  the  descrip 
lions  of  the  anatomical  characters  of  the  diseases  considered  in  the  rest  of  the  volume.  It  is 
believed  that  these  portions  of  the  work  will  serve  as  a  digest  of  the  e-sential  facts  pertaining  to 
general  and  special  pathological  anatomy,  as  far  as  this  important  branch  of  study  bears  upon 
practical  medicine. 

In  the  other  portions  of  the  treatise  many  changes  will  be  found,  which  have  somewhat  en- 
larged the  size  of  the  volume,  in  spite  of  the  omission  of  a  considerable  amount  of  matter,  and 
the  rewriting  of  many  portions  with  a  S|)ecial  view  to  condensation.  Among  the.se  changes  may 
be  mentioned  numerous  improvements  in  the  arrangement,  including  the  cla-sifiaat'on  of  the 
diseases  of  the  nervous  system  on  an  anatomical  in  place  of  a  symptomatic  basis,  and  the  con- 
sideration of  various  disea.'^es  not  embraced  in  previous  editions.  In  short,  the  eliminations, 
substitutions,  and  additions  render  the  present  edition  virtually  a  new  work. 

In  making  changes,  the  author  has  not  been  influenced  by  any  sense  of  obligation  to  maintain 
consistency  of  views  with  the  previous  editions  of  this  treitise,  or  with  other  works  which  he  has 
written.  If  statements  be  found  to  vary  from  those  made  at  a  prior  date,  the  simple  e.vplana- 
tion  is  that  the  latter,  in  the  light  of  more  recent  reflection  and  enlarged  knowledge,  seem  to 
him  no  longer  tenable.  He  has  endeavored  to  regard  his  own  past  writings,  in  this  point  of 
view,  divested  of  the  partiality  of  authorship,  and  to  subject  them  to  as  critical  an  examination 
as  if  they  were  the  writings  of  another. 
JO  Y  THE  S  A. ME  A  VTHOR. 

CLINICAL  MEDICINE;   a  Systematic  Treatise  on   the  Diagnosis 

and  Treatment  of  Diseases.  Designed  for  Students  and  Practitioners  of  Medicine.  In 
one  large  and  handsome  octavo  volume  of  795  pages;  cloth,  $4  50  ;  leather,  $5  60  ; 
half  Russia,  $6.     {Now  Ready.) 

in  this  conntry  as  that  of  the  author  of  two  works 
of  great  merit  ou  special  sulijeci.s,  and  of  numerons 
papers,  exhib'tiag  much  originality  and  extensive 
resfarch.  —  Tlie  Dublin  Journal,  Dec.  1S79. 

There  is  every  reason  to  believe  that  this  book 
will  be  well  received.  The  accive  practitioner  is 
frequently  in  need  of  some  work  that  will  enable 
him  to  obtain  information  in  the  diagnosis  and 
treatment  of  cases  with  comparatively  little  labor. 
Dr.  Flint  has  the  faculty  of  expressing  himself 
clearly,  and  at  the  same  time  so  concisely  as  'o 
enable  the  searcher  to  traverse  the  entire  ground 
of  his  search,  and  at  the  same  time  obtain  all  that 
is  essential,  without  plodding  through  an  intermi- 
nable space. — N.  Y.  Med.  Jour.,  Nov.  1S79 

The  great  object  is  to  place  before  the  reader  the 
latest  observations  and  experience  in  diagnosis  and 
treatuent.  Such  a  w  irk  is  especially  valuable  to 
students.  It  is  complete  in  Us  special  design,  and 
yet  60  condensed,  that  he  can  by  its  aid,  ket'p  up 
with  the  lectures  on  practice  without  neglecting 
other  branches.  It  will  not  escape  the  notice  of  the 
practitioner  that  such  a  work  is  most  valuable  in 
culling  points  in  diagnosis  and  treatment  in  the  in- 
tervals between  the  daily  rounds  of  visits  since  he 
can  in  a  few  minutes  refresh  his  memory,  or  learn 
the  latest  advance  in  the  treatment  of  diseases  which 
demand  his  instant  attention. — Cincinnati  Lancet 
and  iJiinic,  Oct.  25,  1879. 


The  eminent  teacher  who  has  written  the  volume 
under  consileration  h.;s  recognized  the  needs  of 
the  American  profession,  and  the  result  is  all  that 
wo  could  wish.  The  style  in  which  it  if  written  is 
peculiarly  the  author's;  it  is  clear  and  forcible,  and 
marked  by  those  characteristies  which  have  ren- 
dered him  one  of  the  best  writers  and  teachers  this 
conntry  has  ever  produced.  We  have  not  space  for 
BO  full  a  consideration  of  this  remarkable  work  as 
we  would  desire. — S.Louis  Clin.  Record,  Oct.  1879. 

It  is  here  that  the  skill  and  learning  of  the  great 
clinician  are  displayed  He  has  given  us  a  store- 
house of  medical  knowledge,  excellent  for  the  stu- 
dent, convenient  for  the  practitioner,  the  result  of  a 
long  life  of  the  most  faithful  clinical  work,  collect- 
ed by  an  energy  as  vigilant  and  systematic  as  un- 
tiring, and  weighed  by  a  judgment  no  less  clear 
than  his  observation  is  close.— Archives  of  Medi- 
cine, Deo.  1S79. 

To  give  an  adequate  and  useful  conspectus  of  the 
extensive  field  of  modern  clinical  medicine  is  a  task 
of  no  ordinary  ditficulty  ;  bnt  to  accomplis?i  this 
consistently,  with  brevity  and  clearness,  the  different 
subjects  and  their  several  parts  receiving  the  atten- 
tion which,  relatively  to  their  importance,  medical 
opinion  claims  for  them,  is  still  more  ditficult.  This 
t.isk  we  feel  bound  to  say  has  been  executed  with 
more  than  partial  success  by  Dr  Flint,  whose  name 
is  already  familiar  to  students  of  advanced  medicine 


B 


Y  THE  SAME  AUTHOR. 

ESSAYS    ON    CONSERVATIVE   MEDICINE    AND   KINDRED 

TOPICS.     In  one  very  handsome  royal  l2rao.  volume.     Cloth,  $1  38.     {Jitst  Issued.) 


DAVIS'S  CLINICAL  LECTURES  ON  VARIOUS 
I JIPO  RTANT  DISEASES  ;  being  a  collection  of  the 
Clinical  Li'ctures  delivered  in  the  Medical  Wards 
of  Mercy  Hospi;al,  Chicago.  Edited  by  Frank  H 
Davis,  M.D.  Second  edition,  enlarged.  In  one 
handsome  royal  12[no.  volume.     Cloth,  $1  7.5. 

THE  CYCLOPJEDIA  OF  PRACTICAL  MEDICINE: 
comprising  Treatises  on  the  Nature  and  Treatment 
of  Diseases,  Materia  Medica  and  Therapeutics,  Dis- 


eases of  Women  and  Children,  Medical  Jurispru- 
dence, etc.  etc.  By  Dua'Alison,  Forbes,  Tweedib, 
and  CoNOLiiY.  In  four  large  super-royal  octavo 
volumes,  of  32.54  double-colnmued  pages,  strongly 
and  handsomely  bound  in  leather,  $1.5;  cloth.  $11. 

sturges's  introduction  to  the  study  of 

CLINICAL  medicine.  Being  a  Guide  to  the  In- 
vestigation of  Disease.  In  one  handsome  12mo. 
volume,  cloth,  $1  2.5.    {Lately  Issued.) 


16   Henry  C.  Lea's  Son  &  Co.'s  Publications — {Practice  of  Medicine). 
JJIGHARDSON  [BENJ.  W.),  M.D.,  F.R.S.,  M.A.,  LL.D.,  F.S.A., 

-*-*'        Fellow  nfthf.  Royal  College  of  Phi/fiioians,  London. 

PREYENTIVE  MEDICINE.    In  one  octavo  volume  of  about  500  pages. 

{In.  Press.) 

Tbe  immerse  strides  taken  by  medical  science  during  the  last  quarter  of  a  century  have  had 
no  more  conspicuous  field  of  progress  than  the  causation  of  disease.  Not  only  has  this  led  to 
marked  advance  in  therapeutic^,  but  it  has  given  rise  to  a  virtually  new  department  of  medi- 
cine— the  prevention  of  disease — more  important,  perhaps,  in  its  ultimate  results  than  even  the 
investigation  of  curative  processes.  Yet  thus  far  there  has  been  no  attempt  to  gather  into  a 
fystematic  and  intelligible  shape  the  accumulation  of  knowledge  ttus  far  acquired  on  this  most 
interesting  subject.  Fortunately,  the  task  h's  been  at  last  undertaken  by  a  writer  who  of  all 
others  is,  perhaps,  besi  qualified  for  its  performance,  and  the  result  of  his  labors  can  hardly  fail 
to  mark  an  epoch,  in  the  history  of  medical  science.  The  plan  adopted  for  the  execution  of  this 
novel  design  can  best  be  explained  in  his  own  words  : — 

"  With  the  object  here  expressed  I  write  this  volume.  I  have  nothing  to  say  in  it  that  has 
any  relation  to  the  cure  of  disease,  but  I  base  it  nevertheless  on  the  curative  side  of  medical 
learning  In  other  words,  I  trace  the  diseases  from  their  a'ctual  representation  as  they  exist 
before. us,  in  their  natural  progress  after  their  birth,  as  far  as  I  am  able,  back  to  their  origins, 
and  try  to  seek  the  conditions  out  of  which  they  spring.  Thereupon  I  endeavor  further  to 
analyze  those  conditions,  to  see  how  far  they  are  removable  and  how  far  they  are  avoidable." 


VU'OODBURY  {FRANK),  M.D., 

'  '  Physician  to  the  Gerraan  JSotpital,  Phil 


iladelphia,  late  Chief  Assist,  to  Med.  Clinic,  Jeff.  College 
Hospital,  etc. 

A    HANDBOOK   OF   THE   PRINCIPLES  AND   PRACTICE    OF 

Medicine  ;  for  the  use  of  Students  and  Practitioners.     Based  upon  Husband's  Handbook 
of  Practice.     In  one  neat  volume,  royal  12mo.     {Freparing.) 


J^OTHERGILL  [J.  MILNER),M.D.  Edin.,  M.R.C.P.  Land., 

*■  Asst.  Phys.  to  the  West  hond,  Hosp.  ;  As.H.  Phy.s\  to  the  City  of  Lond.  Hosp.,etc. 

THE  PRACTITIONER'S  HANDBOOK  OF  TREATMENT;  Or, the 

Principles  of  Therapeutics.     Second  edition,  revised  and  enlarged.     In  one  very  neat 

octavo  volume  of  about  650  pages.     Cloth,  $4  00;  very  handsome  half  Russia,  $5  50. 

(Just  Ready.) 

The  call  for  a  second  edition  of  Dr.  Fothergill's  work  has  been  met  by  the  author  with  a 

revision  performed  in  no  perfunctory  manner.     The  entire  subject-matter  has  been  submitted 

to  a  most  careful  and  exhaustive  scrutiny,  and  much  new  material  been  added,  including  articles 

on   "The  Functional  Disturbances  of  the  Liver,"   "The  Means  of  Acting  on  the  Respiratory 

Nerve  Centres,"    "The    Reflex    Consequences  of  Ovarian    Irritation,"    "When   Not  to  Give 

Iron,"   "Artificial  Digestion,"  etc.,  thus  presenting  a  complete  reflex  of  the  existing  condition 

of  therapeutical  science. 

The  junior  luembsrs  of  the  pr  fession  will  find  in 
it,  a  wuik  that  .'ihould  not  only  be  read,  but  care- 
fully isfuded  It  will  assist  them  in  the  proper 
Neiection  and  combiaatiou  of  thenpeutical  agenis 
best  adapted  to  each  case  and  couditi'jn,  and  enable 
thfcjin  to  prescribe  iiitellitrently  and  .-^uccesslully. 
Tu  d(.  full  justice  to  a  work  of  this  ^c  pe  and  char- 
acter will  be  iiupossiblti  in  a  review  of  ihis;  kind. 
The  book  it.sclf  mast  be  read  to  be  fully  appreciated. 
— St.  Louis  Courier  of  M'dicine,  Nov   1S80. 

Tbe  author  merits  the  thanks  of  every  well-edu- 
cated physician  for  hia  efforts  toward  rationalizing 
tlie  treatment  of  diseases  upon  the  scientific  basis 
of  (ihysiology.  E-ejy  chapter,  every  liue,  has  the 
iiiiiires.s  of  a  master  hand,  and  while  the  work  is 
thoroughly  t-cientific  in  ►'very  particular,  it  presents 
to  tbe  thoiightul  reader  all  the  charms  ajd  beau- 
ti('s  of  a  well-written  novel.  No  physician  can 
well  afford  to  be  without  this  valuable  work,  for  its 


originality  makes  it  fill  a  niche  in  medical  litera- 
ture hitherto  vacant. — Nashville  Journ.  of  Med. 
and  Surg.,  Oct.  ISSO. 

To  the  great  bulk  of  practitioners  this  work  needs 
no  introduction,  being  already  well  and  favorably 
known  to  them  For  that  class,  however,  which  is 
ev.ar  new,  the  educated,  but  inexperienced  practi- 
tioner, to  whom  Dr.  Fothergill  specially  addresses 
himself  aud  to  whom  probably  he  is  most  useful, 
we  may  state  something  of  the  general  character  of 
this  work.  Throughout  the  worS,  while  room  is  left 
for  difference  of  opinion  in  matters  of  detail,  the 
main  courses  of  treatment  are  so  carefully  founded 
on  well-established  principles,  that  no  essential  dif- 
ference is  felt  to  be  possible  The  closing  chapter 
c  HI  tains  much  concentrated  worldly  wisdom  ;  and, 
if  carefully  read,  digested,  and  assimilated,  will,  in. 
mauy  an  emergency,  stand  the  young  medical  man 
in  good  stead. —  Lond.  Med.  Record,  Oct.  12,  1S80. 


VfTA  TSON  ( THOMAS),  M.D.,  ^c. 

LECTURES    ON    THE     PRINCIPLES    AND    PRACTICE    OF 

PHYSIC.  Delivered  at  King's  College,  London.  A  new  American,  from  the  Fifth  re- 
vised and  enlarged  English  edition.  Edited,  with  additions,  and  several  hundred  illus trfi- 
tions,  by  Henry  Hartshorne,  M.D.,  Professor  of  Hygiene  in  the  University  of  Penn- 
sylvania.    In  two  large  and  handsome  8vo.  vols.    Cloth,  $9  00  ;  leather,  $11  00.     (Lately 

Published.)  

fJA R TSHORNE  ( UENR Y),  M. D., 

■*-*  Professor  of  Hygie.ne  in  the  Univer.iity  of  Pennsylvxnia 

ESSENTIALS  OF  THE  PRINCIPLES  AND  PRACTICE  OP  MEDI- 

CINE.  A  handy-book  forStudents  and  Practitioners.  Fourth  edition,  revised  and  im- 
proved. With  about  one  hundred  illustrations.  In  one  handsome  royal  12mo.  volume, 
of  about  550  pages,  cloth,  %2  63  ;  half  bound,  $2  88.     (Lately  Issued.) 


Henry  C.  Lea's  Son  &  Co.'s  Publications — {Practice  of  Medicine),    It 
'OEYNOLDS  {J.  RUSSELL).  M.D., 

J-V     _    Pro/,  of  the  PrinciplKH  and  Prootice  o/ Medicine  in  Univ.  College,  London. 

A  SYSTEM  OP  MRDK/INK   with  Notrs  and  Additions  by  HknryIIarts- 
HORNE,  M.D.,  late  Professor  of  Hygiene  in  the  University  of  Penna.      In  three  large  and 
hiindsome  octavo  volumes,  containing  ;-i0.')2  closely  printed  double-oolumned  pjiges.  with 
numerous  illustrations.      Sold  only  by  suhsrrijiiion.      Price  per  vol.,  in  clofh,  $5.00;   in 
sheep,  $6.00:  half  Russia,  raised  band.s,  $6.50.     Per  set  in  cloth,  $15;  sheep,  $18;  half 
Russiii,  $19.50 
Volume  I.   {jtist  ready)  contiiins  General  Diseases  and  Diseases  op  the  Nervous  System. 
Volume  II.    (just  ready)  cont;iins  Diseases  of  Respiratory  and  Circulatory  Systems. 
Volume    ITI.    (just  ready)    contains    Diseases  op   the  Digestive  and  Blood  Glandular 
Systems,  op  the  Urinary  Organs,  of  the  Female  Reproductive  System,  and  of  the 
Cutaneous  System. 
Reynolds's  System  op  Medicine,  recently  completed,  has  acquired,  since  the  first  nppearnnce 
of  the  first  volume,  the  well-deserved  reputation  of  being  the  work  in  which  moJern   British 
medicine  is  presented  in  its  fullest  and  most  practical  form.     This  could  scarce  be  otherwise  in 
view  of  the  fact  that  it  is  the  result  of  the  collaboration  of  the  leading  minds  of  the  profession, 
each  subject,  being  treated  by  some  guntleman  who  is  regarded  as  its  highest  authority — as  for 
instance.   Diseases  of  the  Bladder  by  Sir  Henry  Thompson,   Malpositions  of  the  Uterus  by 
Graily  Hewitt,   Insanity  by  Henry  Maudsley,  Consumption  by  J.  Hughes  Bennet,   Dis- 
eases of  the  Spine  by  Char<les  Bland  Radcliffe,  Pericarditis  by  Francis  Sibson,  Alcoholism 
by  Francis  E.  Anstie,   Renal  Affections  by  William  Roberts,   Asthma  by  Hvdb   Salter, 
Cerebral  Affections  by  H    Charlton  Bastian,  Gout  and  Rheumatism  by  Alfred  Baring  Gak- 
rod,   Cmstitntinnil  Syphilis  by  Jonathan   Hutchinson,  Diseases  of  the  Stomach  by  Wilson 
Fox,  Diseases  of  the  Skin  by  Balmanno  Squire,   Affections  of  the  Larynx  by  Morell  Mac- 
FBNZIE,   Diseases  of  the  Rectum  by  Blizard  Curling,   Diabetes  by  Lauder  Brunton,   Intes- 
tinal Diseases  by  John  Syer  Bristowe,  Catalepsy  and  Somnambulism  by  Thomas  King  Cham- 
bers, Apople.xy  by  J.  Hughlinss  Jackson,  Angina  Pectoris  by  Professor  Gairdner,  Emphy- 
sema of  the  Lungs  by  Sir  William  Jenner,  etc    etc.     All  the  leading  schools  in  Great  Britain 
h.ive  contributed  their  best  men  in  generous  rivalry,  to  build  up  this  monument  of  medical  .sci- 
ence.    St.  Bartholomew's,  Guy's,  St  Thomas's,  University  College,  St  Mary's  in  London,  while 
the  Edinburgh,  Glasgow,  and  Manchester  schools  are  equally  well  represented,  the  Army  Medical 
School  at  Netley,  the  military  and  naval  services,  and  the  public  health  boards.     That  a  work 
conceived  in  such  a  spirit,  and  carried  out  under  such  auspices  should  prove  an  indispensable 
treasury  of  facts  and  experience,  suited  to  the  daily  wants  of  the  practitioner,  was  inevitable,  and 
the  success  which  it  has  enjoyed  in  England,  and  the  reputation  which  it   has  acquired  on  this 
side  of  the  Atlantic,  have  sealed  it  with  the  approbation  of  the  two  pre-eminently  practical  nations. 
Its  large  size  and  high  price  having  kept  it  beyond  the  reach  of  many  practitioners  in  this 
country  who  desire  to  possess  it,  a  demand  has  arisen  for  an  edition  at  n  price  which  shall  ren- 
der it  accessible  to  all.     To  meet  this  demand  the  present  edition  has  been  undertaken.     The 
five  volumes  and  five  thousard  pages  of  the  original  have,  by  toe  use  of  a  smaller  type  and  double 
columns,  been  compressed  into  three  volumes  of  over  three  thousand  pages,  clearly  and  hand- 
somely printed,  and  offered  at  a  price  which  renders  it  one  of  the  cheapest  works  ever  presented 
to  the  American  profession. 

But  not  only  is  the  American  edition  more  convenient  and  lower  priced  than  the  English; 
it  is  also  better  and  more  complete.  Some  years  having  elapsed  since  the  .appearance  of  a 
portion  of  the  work,  additions  are  required  to  bring  up  the  subjects  to  the  existing  condition 
of  science.  Some  diseases,  also,  which  are  comparatively  unimportant  in  England,  require  more 
elaborate  treatment  to  adapt  the  articles  devoted  to  them  to  the  wants  of  the  American  physi- 
ci.in  ;  and  there  are  points  on  which  the  received  practice  in  this  country  differs  from  that 
adopted  abroad.  The  supplying  of  these  deficiencies  has  been  undertaken  by  Henry  Harts- 
HuRNE,  M.D.,  late  Professor  of  Hygiene  in  the  University  of  Pennsylvania,  who  has  endeavored 
to  render  the  work  fully  up  to  the  day,  and  as  useful  to  the  American  phy.sician  as  it  has  proved 
to  be  to  his  English  brethren.  The  number  of  illustrations  has  also  been  largely  increased,  and 
no  effort  spared  to  render  the  typographical  execution  unexceptionable  in  every  respect. 


Really  too  much  praise  can  scarcely  be  given  to 
this  noble  book.  It  is  a  cyclopsedia  of  medicine 
written  by  some  of  the  best  men  of  Europe.  It  is 
full  of  usefol  inforrnatiou  such  as  one  finds  frequent 
need  of  in  one's  daily  work  As  a  boi)k  of  reference 
it  is  invaluable.  It  is  up  with  the  times.  It  is  clear 
acid  concentrated  in  style,  and  its  form  is  worthy 
of  its  famous  publisher.  —  Louisville  Mtd.  News, 
Jan.  31,  ISSO. 

"  Reynolds'  System  of  Medicine"  is  justly  con- 
sidered the  most  popular  work  on  the  principles  and 
practice  of  medicine  in  the  English  language  The 
euatributors  to  this  work  are  gentlemen  of  well- 
known  reputation  on  both  sides  of  the  Atlantic. 
Each  gentleman  has  si  riven  to  make  his  part  of  the 
Work  as  practical  as  pos->ible,  and  the  information 
contained  is  such  as  is  needed  by  the  busy  practi- 
ti  jner.  — iSt.  Louis  Med.  and  fiurg.  Journ.,3si,n.  '80. 

Dr.  Hartsborne  has  made  ample  additions  and 
revision.s,  all  of  which  give  increa^^ed  value  to  the 
volume,  and  render  it  more  useful  to  the  Ameri- 
c-in  practitioner.  There  is  no  volume  in  English 
medical  lite  ature  more  valuable,  and  every  pur- 
chuser  will,  on  becoming  familiar  with  it,  congrat- 
nlate  himself  on   the  poPseKKion   of  this  va.«t  Rtr>re- 

house  of  information,  in  regard  to  so  many  of  the 


subjects  with  which  he  should  be  familiar — Gail- 
lard's  Med.  Journ.,  Feb.  ISSO. 

There  is  no  medical  work  which  we  have  in  times 
past  more  frequently  and  fully  consulted  wlieu  per- 
plexed by  doubts  as  to  treatment,  or  by  having  un- 
usual or  apparently  inexplicable  symproms  pre- 
sented to  us  than  "Reynolds'  Sys'em  of  Medicine." 
Among  its  contributors  are  gentlemen  who  are  as 
well  known  by  reputation  upon  this  side  of  the 
Atlantic  as  in  Great  Britain,  and  whose  right  to 
speak  witb  authority  upon  the  subjects  about 
which  they  have  written,  is  recognized  the  world 
ovc.  They  have  evidently  striven  to  make  their 
essays  as  practical  as  possible,  and  while  these  are 
sufficiently  full  to  entitle  them  to  the  name  of 
monographs,  they  are  not  loaded  down  with  such 
an  amount  of  detail  as  to  render  them  wearisome 
to  the  general  reader.  In  a  word,  they  contain  just 
that  kind  of  information  which  the  busy  practitioner 
frequently  finds  himself  in  need  of.  In  order  that 
any  deficiencies  may  be  supplied,  the  publishers 
have  committed  the  preparation  of  the  book  for  the 
press  to  Dr.  Henry  Hartsborne,  who^e  judicious 
notesdistrihuted  throughout  the  volume  afford  abun- 
dant evidence  of  the  thoroughness  of  ihe  revision  to 
which  he  has  subjected  it, — Am.  Jour. Med.  Sciences, 
Jan.  1880. 


18     Henry  C.  Lea's  Son  &  Co.'s  Publications — {Prao.  of  Med.,  &c.). 


T?ARTHOLOW  (ROBERTS),  A.M.,  M.D..  LL.D. 

-*-'  Prof,  of  Materia  Medica  and  General  Therapeutics  in  the  Jeff  Me.d.  Goll.  of  Phila.,  etc. 

A  PRACTICAL  TREATISE  ON  ELECTRICITY  IN  ITS   APPLL 

CATION  TO  MEDICINE.  In  one  very  handsome  12mo.  volume  of  about  300  pages, 
with  numerous  illustrations.     {In  press.) 

The  constantly  increasing  therapeutic  use  of  electricity,  and  the  absence  of  a  concise  guide 
suited  to  the  wants  of  the  general  practitioner,  have  induced  the  author  to  prepare  the  present 
volume.  His  object  has  been  to  present  the  most  advanced  state  of  existing  knowledge  in  a 
form  divested  of  unnecessary  technicalities,  keeping  constantly  in  view  the  practical  needs  of 
the  student  and  physician. 

As  the  volume  is  founded  upon  a  course  of  lectures  delivered  in  the  Jefferson  Medical  College 
during  1880,  its  adaptation  to  its  purpose  is  insured.  Dr.  Bartholow's  power  of  lucid  exposition 
is  well  known,  and  is  particularly  desirable  in  a  subject  such  as  this,  treated  from  the  stand- 
point of  the  general  practitioner  and  not  of  the  specialist. 

PINLAYSON  {JAMES),  M.D., 

-*-  Physician  and  Lecturer  on  Clinical  Medicine  in  the  Glasgow  Western  Infirmary ,  etc. 

CLINICAL    DIAGNOSIS;    A    Handbook    for    Students   and    Prac- 

titioners  of  Medicine.  In  one  handsome  12mo.  volume,  of  546  pages,  with  85  illustra- 
tions.    Cloth,  $2  63.     {Just  Issued.) 


The  book  is  an  excelleat  one,  clear,  concise,  conve- 
nient, practical.  It  is  replete  with  the  very  know- 
ledge the  -student  needs  when  he  quits  the  lecture- 
room  and  the  laboratory  for  the  ward  and  sick-room, 
and  does  not  lack  in  information  that  will  meet  the 
wants  of  experienced  and  older  men. — Phila.  Med. 
Times,  Jan.  4,  1879. 

This  is  one  of  the  really  useful  books.    It  is  attrac- 


tive from  preface  to  the  final  page,  and  ought  to  be 
gi  ven  a  place  on  every  office  table,  because  it  contains 
in  a  condensed  form  all  that  is  valuable  in  semeiology 
and  diaguostics  to  be  found  in  bulkier  volumes,  and 
because  in  its  arrangement  and  complete  index,  it  is 
unusually  convenient  for  quick  reference  in  any 
emergency  that  may  come  upon  the  busy  practitioner. 
—N.  O.  Med.  Journ.,  Jan.  1879. 


J^JITCHELL  {S.  WEIR),  M.D., 

Pkys.  to  Orthopcedic  Hospital  and  the  Infirmary  for  Dis.of  the  N-rxoxis  System,  Phila.,  etc.  etc. 

LECTURES    ON    DISEASES    OF    THE     NERVOUS    SYSTEM", 

ESPECIALLY  IN  WOMEN.     In  one  very  handsome  ]2mo.  volume  of  about  250  pages, 
with  five  lithographic  plates.      {Shortly.) 


H 


AMILTON  (ALLAN  McLANE),  M.D., 

Attending  Phy.noian  at  the  Iloxpital  for  Epileptica  and  Paralytics,  Blackwell's  Island,  N.  1'., 
and  at  the  Out-Patients'  Department  of  the  Neio  Yorl;  Hnr-^iif'^l. 

KERVOUS DISEASES; THEIR  DESCRIPTION  AND  TREATMENT. 

In  onehandsome  octavo  volume  of  512 pages,  with  53  illus. ;  cloth,  $3  50.     {Lately  Issued.) 


CLINICAL  OBSERVATIONS  ON  FUNCTIONAL 
NERVOUS  DISORDERS  By  C.  HandpieldJokeb, 
M.D.,  Physician  to  St.  Mary's  Hospital,  &c.  Sec- 


ond American  Edition.    In  one  handsome  octavo 
volume  of  3-18  pages, cloth,  $3  25  . 


M 


ORRIS  [MALCOLM),  M.D., 

Joint  Lecturer  on  Dermatology ,  St.  Mary's  Hospital  Med.  School. 

SKIN  DISEASES,  Including  their  Definitions,  Symptoms,  Diagnosis, 

Prognosis,  Morbid  Anatomy,  and  Treatment.    A  Manual  for  Students  and  Practitioners. 

In  one  12mo.  volume  of  over  300  pages.    With  illustrations.    Cloth,  $1  75.     (NowReady.) 

To  physicians  who  would  like  to  know  something  i  appliances  of  cutaneous  medicine-    He  has  produced 

about  skiu  diseases,  so  that  when  a  patient  presents  i  a  plain,  practical  book,  by  aid  of  which,  who   so 

chooses  may  tr-iin  his  eye  to  the  recognition  of 
light  but  significant  differences.  The  descriptions 
are  neither  too  vasrue  nor  orer-vefiued  ;  the  direc- 
tions for  treatment  are  clear  and  succinct. — London 
Brain,  April,  18S0. 

The  author  has  handled  his  subject  in  a  clear  and 
concise  manner,  and  as  a  text-book  to  students  Ms 
manual  will  be  found  useful. — Medical  and  Surgi- 
cal Reporter,  March  27,  1880. 

The  author's  task  has  been  well  done  and  has  pro- 
duced one  of  the  best  recent  works  upon  the  difUeult 
subject  of  which  ittreats  ;  ttiereisno  workpublished 
which  gives  a  better  view  of  the  elementary  facts 
and  principles  of  dermatology. — Ne70  Orleans  Medi- 
cal and  Surgical  Journal,  April,  1880. 

This  excellent  little  book  is  the  fii'st  work  of  a 
distinguished  pupil  of  Jonathan  Hutchinson;  it  re- 
commends itself  above  all  by  its  clearness,  method, 
and  precision — Annaleii  de  Dirir^atologie  et  de 
Syphiligraphie,  Paris,  25  April,  1880. 


him.self  for  relief  they  can  make  a  correct  diagnosis 
and  prescribe  a  rational  treatment,  we  unhesitatingly 
jrecommend  this  little  book  of  Dr.  Morris.  The  affec- 
tions of  the  skin  are  described  in  a  terse,  lucid  man- 
ner, and  their  several  characteristics  so  plainly  set 
forth  that  diagoosis  will  be  easy.  The  treatment 
in  each  case  is  such  as  the  experience  of  the  most 
eminent  dermatologists  advise. — Gincinnati  Medi- 
cal Sews,  April,  1880- 

This  is  emphatically  a  learner's  book  ;  for  we  can 
safely  say,  so  far  as  our  judgment  goes,  that  in  the 
whole  range  of  medical  literature  of  a  like  scope, 
there  is  no  book  which  for  clearness  of  expression, 
and  methodical  arrangement  is  better  adapted  to 
promote  a  rational  conception  of  dermatology,  a 
branch  confessedly  difficult  and  perplexing  to  the 
beginner- — St.  Louis  Courier  of  Medicine,  April, 
1880. 

The  author  of  this  manual  has  evidently  a  full  and 
intimate  acquaintance  with  the  literature  of  derma- 
tology, and  with  the  most  recent  developments  and 


fpOX  (  TILBURF),  M.D.,  F.R.C.P.,  and  T.  C.  FOX.  B.A.,  M.R.G.S., 

•*-  Phy.fioian  to  the  Department  for  Skin  Diseases,  University  College  Ho.siiitnl. 

EPITOME  OF  SKIN  DISEASES.     WITH  FORMULA.     For  Stu- 

DENTS  AND  Practitionkrs .    Second  edition,  thoroughly  revi.«ed  and  greatly  enlarged.  In 
one  very  handsome  12mo.  volume  of  216  pages.    Cloth,  $1  3S.     {Just  Issued.) 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Dis.ofthe  Chest, dc),   19 


PLINT  {AUSTIN),  M.D., 

PritfeHffor  of  the.  PrincipUe  and  PrantioH  of  Medicine  in  Bellevue  Hospital  Med.  College,  N.  T. 

A  MANUAL  OF  PERCUSSION  AND  AUSCULTATION;  of  the 

Physical  Dingnosis  of  Diseiipes  of  the  Lungp  and  Heart,  and  of  Thoracic  AneuriFm. 
Second  edition.     In  one  bandpome  royal  12mo.  volume  :  cloth,  $1  63.     (Just  Ready.) 

Med.   and    Surg.    Reporter, 


Prof.  Flint  Ih  so  well  V:uowa  hk  a  medical  teacher 
and  writer  that  it  Kepm«  superfluous  to  ptate  that 
thpgiiiiject  has  lieeu  treatpd  in  a  thorough  and  sys- 
(fttnatic  tnanaer.  lu  reviKinj;  it  for  a  second  ed;tion 
the  auth  ir  has  con  flu  ed  liiinself  to  such  add  ii  ions  as 
seem  likely  to  reader  it  more  useful,  not  only  to 
students  engaged  in  the  practical  study  of  the  sub- 
ject, but  also  to  practitioners  as  a  handbook  for 
ready  reference,  and  we  do  not  hesitate  in  saying 
that  it  would  prove  a  valuable  addition  to   every 


pliysician's  library.- 
March  18,  1S80, 

The  little  work  before  ns  has  already  become  a 
standard  one,  and  has  become  exiensively  adopted 
as  a  text-book.  Ttii^re  is  certainly  none  better.  It 
contains  the  snb.slance  of  the  lessons  which  the 
author  has  fjr  m  <ny  years  given,  in  connection  with 
practical  instruction  in  auscultation  and  percnsi-lon, 
to  private  classes,  composed  of  medi'-al  stadents  and 
practitioners.  — Cmcfranatl  Med.  News,  Feb.  ISSO. 


or   THE  SAME   AUTHOR. 

PHTHISIS:  ITS  MORBID  ANATOMY,  ETIOLOGY,  SYMPTOM- 
ATIC EVENTS  AND  COMPLICATIONS,  FATALITY  AND  PROGNOSIS,  TREAT- 
MENT AND  PHYSICAL  DIAGNOSIS;  in  a  series  of  Clinical  Studies.  By  Austin 
FfjiNT,  M.D.,  Prof,  of  the  Principles  and  Practice  of  Medicine  in  Bellevue  Hospital  Med. 
College,  New  York.     In  one  handsome  octavo  volume  :  $3  50.     (Lately  Issued.) 


-DY  THE  SAME  AUTHOR. 

A  PRACTICAL  TREATISE  ON  THE  DIAGNOSIS,  PATHOLOGY, 

AND  TREATMENT  OP  DISEASES  OF  THE  HEART.     Second  revised  and  enlarged 

edition.     In  one  octavo  volume  of  550  pages,  with  a  plate,  cloth,  $4. 

Dr.  Flint  chose  a  difficul'  subject  for  his  researches,  i  and  clearest  practical  treatise  on  those  subjects,  and 

aad  has  shown  remarkable  power."?  of  observation    ihould  be  in  the  hands  of  all  practitioner.'-  and  stu- 

and  reflection,  as  well  as  greatindustry,  in  his  treat-    dents.  It  is  a  credit  to  American  medical  literature. 

ment  of  it.    His  book  must  be  considered  the  fullest  '  —Amer.  Journ.  of  the  Med.  Sciences,  July,  186U. 

J)  T  THE  SA  ME  A  UTHOR .  ' 

A  PRACTICAL  TREATISE  OX  THE  PHYSICAL  EXPLORA- 
TION OF  THE  CHEST  AND  THE  DIAGNOSIS  OF  DISEASES  AFFECTING  THE 
RESPIRATORY  ORGANS.  Second  and  revised  edition.  In  one  handsome  octavo  volume 
of  595  pages.'cloth,  $4  50. 


B 


ROWN  (LENNOX),  F.R.G.S.  Ed., 

Senior  Surgeo7i  fothe  Central  London  Throat  and  Ear  Hospital,  etc. 

THE  THROAT   AND  ITS  DISEASES.     With  one  liiinclred  Typical 

Illustrations  in  colors,  and  fifty  wood  engravings,  designed  and  executed  by  the  .anthor. 
In  one  very  handsome  imperial  octavo  volume  of  361  pages  ;  cloth,  $5  00.    (Just  Ready.) 


OmiLER  (CARL),  M.D., 

Aj  Lecturer  on  Laryngoscopy  at  the  Univ.  of  Penna  ,   Chief  of  the  Throat  Dispensary  at  the 

Univ.  Hospital,  Phiia.,  etc. 

HANDBOOK  OF  DIAGNOSIS  AND  TRKATMENT  OF  DISEASES  OP 

THE    THROAT   AND    NAS.AL   CAVITIES.      In  one  handsome  royal  12mo.  volume, 
of  156  pages,  with  35  illustrations;  cloth,  $1.      (Just  Ready.) 
We  most  heartily  commend  this  book  as  showing        A  convenient  little  handbook,  clear,  concise,  and 


sound  judgment  iu  practice,  and  peifect  familiarity 
with  the  literature  of  tlie  specialty  it  so  ably  epl' 
tomizes. —  Philada.  Med.  Times,  July  5,  1S79. 


accurate  in  its  method,  and  admirably  fulfilling  its 
purpose  of  bringing  the  subject  of  which  it  treats 
within  the  comprehen.sion  of  the  general  practi- 
tioner.— N.  C.  Med.  Jour.,  June,  1879. 


WILLIAMS'S  PULMONARY  CONSUMPTION;  its 
Nature,  Varieties,  and  Treatment.  With  an  An- 
alysis of  One  Thousand  Cases  to  exemplify  its 
duration.  In  one  neat  octavo  volume  of  about 
.S50  pages  ;  clotb,  $2  50. 

SLADE  ON  DIPHTHERIA;  its  Nature  and  Treat- 
ment, with  an  account  of  the  History  of  its  Pre- 
valence in  various  Countries.  Second  and  revised 
edition.  In  one  DeatroyaI12mo.  volume,  cloth, 
m  2.5. 

WALSHE  ON  THE  DISEASES  OF  THE  HEART  AND 
GREAT  VESSELS.  Third  American  Edition.  In 
1  vol.  8vo.,  420  pp.,  cloth,  $3  00. 

CHAMBERS'S  MANUAL  OF  DIET  AND  REGIMEN 
IN  HEALTH  AND  SICKNESS.  In  one  handsome 
octavo  volume.     Cloth,  $2  75. 

LA  PvOCHE  ON  PNEUMONIA.  I  vol.  8vo.,  cloth, 
of  ■'500  pages.     Price,  $,S  00. 

WILSON'S  STUDENT'S  BOOK  OF  CUTANEOUS 
MEDICINE  and  Dj^p.AfBH  OF  the  Skin.  In  one 
Very  handsome  royal  12mo.  volume.    $3  50. 


FULLER  ON  DISEASES  OF  THE  LUNGS  AND  AIR- 
PASSAGES.  Their  Pathology,  Physical  Diagnosis, 
Symptoms,  and  Treatment.  From  the  second  and 
revised  English  edition.  In  one  handsome  octavo 
volume  of  about  500  pages  :  cloth,  $.8  50. 

SMITH  ON  CONSUMPTION  ;  ITS  EARLY  AND  RE- 
MEDIABLE STAGES.    1  vol.8vo.,pp.254.   $2  25. 

BASHAM  ON  RENAL  DISEASES  :  a  Clinical  Guide 
to  their  Diagnosis  and  Treatment.  With  Illustra- 
tions. Id.  one  12mo.  vol.  of  304  pages,  cloth,  $2  00. 

LECTURES  ON  THE  STUDY  OF  FEVER.  By  A. 
Hudson,  M.D.,  M.R.I. A.,  Physician  to  the  Meath 
Hospital.    In  one  vol.  8vo.,  cloth,  ii;2  50. 

A  TREATISE  ON  FEVER.  By  Robert  D.  Ltons, 
K.CC.  In  one  octavo  volume  of  362  pages,  cloth 
*2  25. 

HILLIER'S  HANDBOOK  OP  SKIN  DISEASES,  for 
Students  and  Practitioners.  Second  Am.  Ed.  In 
one  royal  12mo.  vol.  of  358  pp.  Withillustrationa. 
Cloth,  $2  25. 


20    Henry  C.  Lea's  Son  &  Co.'s  Publications — (Venereal  Diseases,  (&o.). 


jyUMSTEAD  [FREEMAN  J.),  M.D.,LL.D., 

^-^        Professor  of  Venereal  Diseases  at  the  Col.  of  Phys.  and  Surg..  New  York,  &c. 

THE  PATHOLOGY  AND   TREATMENT  OF  VENEREAL  DIS- 

EASES.    Including  the  results  of  recent  investigations  upon  the  subject.    Fourth  edition, 
revised   and  largely  rewritten  with   the  co-operation  of  R.  W.  Taylor,  M.D.,  of  New 
York,   Prof,   of  Dermatology  in   the  Univ.  of  Vt.      In  one  large    and  handsome  octavo 
volume  of  8.35  pages,  with  138  illustrations.     Cloth,  $4  75  ;    leather,  $5  75  ;    half  Russia, 
$6  25.      (Now  Ready.) 
This  work,  on  its  first  appearance,  imiiediately  took  the  position  of  a  standard  authority  on 
its  subject  wherever  the  language  is  spoken,  and  the  success  of  an   Italian  translation  shows 
that  it  is  regarded  with  equal  favor  on  the  Continent  of  Europe.   In  repeated  editions  the  author 
labored  sedulously  to  render  it  more  worthy  of  its  reputation,  and  in  the  present  revision   no 
pains    have    been  spared  to  perfect  it  as  far  as  possible.     Several  years  having  elapsed  since 
the  publication  of  the  th^rd  edition,  much  material  has  been  accumulated  during  the  interval 
by  the  industry  of  syphilologi  ts,  and  new  views  have   been   enunciated.     All  this    so   far  as 
confirmed  by  observation  and  experience,  has  been  incorporated;    many  portions  of  the  volume 
been  rewritten,  the  series  of  illustrations  has  been  enlarged  and  improved,  and  the  whole  may 
be  regarded  rather  as  a  new  work  than  as  a  new  edition.    It  is  confidently  presented  as  fully  on 
a  level  with  the   most  advanced  condition  of  syphiiology,  and  as  a  work  to  which  the   practi- 
tioner may  refer  with  the  certainty  of  finding  clearly  and  succinctly  set  forth  whatever  falls 


within  the  scope  of  such  a  treatise 

We  have  to  congratulate  onr  countrymen  upon 
the  rruly  valuable  addition  which  they  have  made 
to  Aniericaa  literature.  The  careful  esumate  of  the 
vulue  of  the  volume,  which  we  have  made,  justifies 
us  in  declaring  that  this  is  the  best  (realise  on 
venereal  diseases  in  the  Engli.sh  langnage,  and,  we 
might  add,  if  there  is  a  better  in  any  other  tongue 
we  cannot  name  it;  there  are  certainly  no  books  in 
which  the  student  or  the  general  practitioner  can 
find  snch  an  excellent  risv.mi  of  the  literature  of 
any  topic,  and  such  practical  suggestions  regarding 
the  tvpatment  of  the  various  comiilicaiions  of  every 
venereal  disease.  We  take  pleasure  in  repeating 
thai  we  believe  this  to  be  the  best  tr-eatise  on  vene- 
real disease  in  the  English  language,  and  we  con- 
gratulate the  authors  upon  their  brilliant  addition 
to  American  medical  literature. — Chieago  Med.  Jour- 
nal and  Examiner,  February,  18S0. 

It  Is,  without  exception,  the  most  valuable  single 
work  on  all  brunches  of  the  subject  of  which  it  treats 
in  any  language.  The  pathology  is  sound,  the  work 
is,  at  the  same  time,  iu  the  highest  degree  practical, 
and  the  hints  that  he  will  get  from  it  for  ihe  man- 
agement of  any  one  case,  at  all  obscure  or  obstinate, 


will  more  than  repay  him  for  the  outlay. — Archives 
of  Medicine,  April,  iS'-'O. 

This  now  classical  work  on  venereal  disease  comes 
to  us  in  its  fourth  edition  rewritten,  enlarged,  and 
materially  improved  in  every  way.  Dr.  Taylor-,  as 
we  had  every  reason  to  exrect,  has  performfd  tb  s 
part  of  his  work  with  uuuoual  excellence.  We  feel 
that  what  hus  been  written  has  doQf  but  scauty  jn.-- 
tice  to  the  merits  of  this  truly  great  treatise. — St. 
Lotiis  Courier  of  Medicine,  Feb.  18S0 

We  find  that  we  have  here  practically  a  new  book 
—  that  the  statemeut  of  the  title  pajte,  as  to  the  fact 
that  it  ha»  been  larsety  rewritten,  is  a  sufficiently 
modest  announcement  for  the  important  changes  iu 
the  text.  A*'ter  a  thorough  examination  of  the  pre- 
sent edition,  we  can  assert  confidently  that  the  enor- 
mous labor  we  have  described  has  been  hei'e  most 
faithfully  and  conscientiously  performed. — Ariier. 
Journ.  Med.  Sci.,  Jan   ISSO. 

It  is  one  of  the  best  general  treatises  on  venereal 
diseases  with  which  we  are  acquainted,  and  is  espe- 
cially to  be  recommended  as  a  guide  to  the  treatment 
of  syphilis. — London  Practitioner,  March,  1S80. 


pULLERIER  [A.), 

>^        Surgeon  to  the  Hopital  du  Midi. 


and         jyUMSTEAD  {FREEMAN  J.). 

Hdi.  -*-'        Professor  iif  Venereal  Diseases  in  the  College oj 

Pliy.<iicians  and  Snrge.o7is.  N.  T. 

AN  ATLAS  OF  VENEREAL  DISEASES.  Translated  and  Edited  by 

Freeman  J.  Bumstead.  In  one  large  imperial  4to.  volume  of  328  pages,  double-columns, 
with  26  plates,  containing  about  160  figures,  beautifully  colored,  many  of  them  the  size  of 
life;  strongly  bound  in  cloth,  $17  00  ;   also,  in  five  pa-ts.  stout  wrappers,  at  $.S  per  part. 
Anticipating  a  very  large  sale  for  this  work,  it  is  offered  at  the  very  low  price  of  Three  Dol- 
lars a  Part,  thus  placing  it  within  the  reach  af  all  who  are  interested  in  this  department  of 
practice.     Glentlemen  desiring  early  impressions  of  the  plates  would  do  well  to  order  it  without 
delay.     A  specimen  of  the  plates  and  text  sent  free  by  mail,  on  receipt  of  25  cents. 


LEE'S  LECTURES  OIT  SYPHILTS  AND  SOME 
FORMS  OF  LOCAL  DISEASE  AFFECTING  PRIN- 
CIPaLLT  the  ORGANS  OF  GENERATION.  In 
one  handsome  octavo  volume;  cloth,  $2  2.7. 


HILL  ON  SYPHILIS  AND  LOCAL  CONTAGIOUS 
DISORDERS.  In  one  handsome  octavo  volume; 
cloth   $S  25. 


WEST  {CHARLES),  M.D., 

Physician  to  the  Hospital  for  Sicli  Children,  London,  Sec. 

LECTURES  ON  THE  DISEASES  OF  INFANCY  AND   CHILD- 

HOOD.  Fifth  American  from  the  sixth  revised  and  enlarged  English  edition.     In  one  large 
and  handsome  octavo  volume  of  678  pages.    Cloth,  $4  50;  leather,  $5  50.  (Lately  Iss7ied.) 


■DT  THE  SAME  AUTHOR.    (Lately Issued.) 

ON  SOME  DISORDERS  OF  THE  NERYOTJS  SYSTEM  IN  CHILD- 

HOOD;  being  the  Lumleian  Lectures  delivered   at  the  Royal  College  of  Physicians  of 
London,  in  March,  1871.     In  one  volume    small  12mo.,  cloth,  $1  00. 


^Y  THE  SA^E  AUTHOR. 

LECTURES  ON  THE  DISEASES  OF  WOMEN.     Third  American, 

from  the  Third  London  edition.     In  one  neat  octavo  volume  of  about  550  pages,  cloth, 
$3  75;  leather,  $4  75. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Dis.  of  Children,  <ic.).   21 


SfMITH  [J.  LEWIS),  M.D., 

Olinicnl  Profe.sfior  r,f  DiaeaoM  of  OMMvn  in  the  Bullevue  ffn^pital  Med.  College,  If.  7. 

A  COMPLETE  PRACTICAL  TREATISE  ON  THE  DISEASES  OF 

CHILDREN.    Fourth  Edition,  revised  and  enlarged.     In  one  handsome  octavo  volume 
of  about  750  pages,  with  illustrations.     Cloth,  $4  50;  leather,  $5  50;  half  Russia,  $6. 
(Now  Ready.) 
The  very  marked  favor  with  which  this  work  has  been  received  wherever  the  English  lan- 
guage is  .spoken,  has  stimulated  the  author,  in   the  preparation  of  the  Fourth  Edition,  to  spare 
no  pains  in  the  endeavor  to  render  it  worthy  in  every  re.'pect  of  a  continuance  of  professional 
confidence.     Many  portions  of  the  volume  have  been  rewritten,  and  much  new  matter  intro- 
duced, but  by  an  earnest  eflfort  at  condensation,  the  size  of  the  work  has  not  been  materially 
increased. 


In  the  period  which  has  elapsed  since  the  third 
edition  of  the  worli,  so  extensive  hnve  been  the  ad- 
vances that  whole  chapters  required  to  be  rewiilten, 
and  hardly  a  page  could  pass  without  some  uiaterinl 
correction  or  addition.  This  labor  has  occupied  the 
writer  closely,  and  he  has  performed  it  conscien- 
tiously, so  that  the  book  may  be  considered  a  faith- 
ful portraiture  of  an  exceptionally  wide  clinical 
experience  in  infantile  diseases,  corrected  by  a  care- 
ful study  of  the  recent  literature  of  the  subject. — 
Med.  and  Surg.  Reijorter,  April  .5,  1879. 

It  is  scarcely  necessary  for  us  to  say  the  work  be- 
fore us  is  a  standard  work  upon  diseases  of  children, 
and  that  no  work  has  a  higher  standing  than  it  upon 
those  affections.  In  consequence  of  its  thorough  re- 
vision, the  work  has  bean  made  of  more  value  than 
ever,  and  may  be  regarded  as  fully  abreast  of  the 
times.  We  cordially  commend  it  to  students  and 
physicians.  There  is  no  better  work  in  the  language 
on  diseases  of  children. — Cincinnati  Med.  News, 
March,  1879. 

The  author  has  evidently  determined  that  It  shall 
not  lose  ground  in  the  esteem  of  the  profession  for 
want  of  the  latest  knowledge  on  that  important 
department  of  medicine.  He  has  accordingly  in- 
corporated in  the  present  edition  the  useful  and 
practical  reiults  of  the  latest  study  and  experience, 


bth  American  and  foreign,  especially  those  beatirg 
on  therapeutics.  Altogether  the  book  has  beea 
greatly  improved,  while  it  has  not  been  greatly- 
increased  in  size.  —  New  Tork  Mtdical  Journal, 
June,  1879. 

This  excellent  work  is  so  well  known  that  an 
extended  notice  at  this  time  would  be  superfluous. 
The  author  has  tai'On  advantage  of  the  demand  for 
another  new  eiliion  to  revise  in  a  most  careful 
manner  the  entire  book  ;  and  the  numerous  correc- 
tions and  additions  evince  a  determinatiin  on  bis 
part  to  keep  fully  abreast  with  the  rapid  progress 
that  is  being  raide  in  the  knowledge  and  treatment 
of  children's  diseases.  By  the  adoption  of  a  some- 
what closer  type,  an  increase  in  size  of  only  thirty 
paces  has  been  necessitated  by  the  new  subject 
matter  introduced. — Boston  Med.  and  Surg .  Jour ., 
May  29,  1S79. 

Probably  no  other  work  ever  published  in  this 
country  upon  a  medical  subject  has  reached  such  a 
height  of  popularity  as  has  this  well-known  trea- 
tise. As  a  text  and  reference-b'iok  it  is  pre-emi- 
nently the  authority  upon  diseases  of  childi.-en.  It 
stands  deservedly  higher  in  the  estimation  of  the 
profession  than  any  other  work  upon  'he  same  sub- 
ject.— Nnxhville  Journ.  of  Med.  and  Sarg.,  Alay, 
1  879. 


^WAFNE  {JOSEPH  GRIFFITHS),  M.D., 

Phy.9ie{an-Accouchfiurt'othe  Britifih  General  Iloxpitol.  &c. 

OBSTETRIC  APHORISMS  FOR  THE  USE  OF  STUDENTS  COM- 

MENCING  MIDWIFERY  PRACTICE.    Second  American,  from  the  Fifth  and  Revised 
London  Edition    with  Additions  by  E|R.  HuTCHiNS,  M.D.   With  Illustrations.   In  one 
neat  12mo.  volume.     Cloth,  $1  25.     [Lately  Issued.) 
*^*  See  p.  3  of  this  Catalogue  for  the  terms  on  which  this  work  is  offered  as  a  premium  to 
subscribers  to  the  American  Journal  op  the  Medical  Sciences. 


CHURCHILL  ON  THE  PDERPEKAL  FEVER  AND 
OTHER  DISEASES  PECULIAR  TO  WOMEN.  1vol. 
Svo.,  pp.  4.50,  cloth      $2  50. 

DEWEES'S  TREATISE  ON  THE  DISEASES  OF  FE- 
MALES. With  illustrations.  Eleventh  Edition 
with  the  Author's  lastimprovementsand  correc- 
tions. In  one  octavo  volume  of  536  pages,  with 
plates,  cloth.    $3  00. 


MEIGS  ON  THE  NATURE,  SIGNS,  AND  TREAT- 
MENT OF  CHILDBED  FEVEK.  1  vol.  Svo.,  pp. 
36S.  cloth.    $2  to. 

ASHWELL'S  PRACTICAL  TREATISE  ON  THE  DIS- 
EASES PECULIAR  TO  WOMEN.  Third  American, 
from  the  Third  and  revised  London  edition.  1  vol. 
8vo.,  pp.  528,  cloth.    $3  50. 


H 


O 


ODGE  {HUGH  L.),  M.D., 

Emeritiis  Professor  of  Obstetrics,  &c.,  in  the  University  of  Pennsylvania. 

ON  DISEASES  PECULIAR  TO  WOMEN  ;  including  Displacements 

of  the  uterus.  With  originalillustrations.  Second  edition,  revised  and  eiil..rged.  In 
one  beautifully  printed  octavo  volume  of  5.31  pages,  cloth,  $4  50, 

'HURCHILL  {FLEETWOOD),  M.D.,  M.R.I.A. 
ON  THE  THEORY  AND  PRACTICE  OF  MIDWIFERY.    A  new 

American  from  the  fourth  revised  and  enlarged  London  edition.  With  notes  and  additions 
by  D.  Francis  Condie,  M.D.,  author  of  a  Practical  Treatise  on  the  Diseases  of  Chil- 
dren, &c.  With  one  hundred  and  ninety-four  illustrations.  In  one  very  handsome  octavo 
volume  of  nearly  700  large  pages.     Cloth,  $4  00  ;  leather,  $5  00. 


MONTGOMERY'S  EXPOSITION  OP  THE  SIGNS 
AND  SYMPTOMS  OF  PREGNANCY.  With  two 
exquisite  colored  plates,  and  numeronswood-cuts. 
Tn  1  fnl.fivo..nfnearlvfi'^onp..clotb,iS3  75. 

CONDIE'S  PRACTICAL  TREATISE  ON  THE  DIS- 
EASES OF  CHILDREN.  Sixth  edition,  revised 
and  augmented.  In  one  large  octavo  volume  of 
nearly  8f"0  closely-printed  pagea,  cloth,  $o  26  ; 
leather,  $6  25. 


RIGBY'S  SYSTEM  OF  MIDWIFERY.  With  notes 
and  Additional  Illustrations.  Second  Ameritan 
sdition.  One  volume  octavo,  cloth,  422  pages, 
*2  .50. 

SMITH'S  PRACTICAL  TREATISE  ON  THE  WAST- 
ING DISEASES  OF  INFANCY  AND  CH.LDHOOD. 
Second  American,  from  the  second  revi.'^ed  and 
enlarged  Euslish  edition.  In  one  handsome  octa- 
vo volume,  cloth,  $2  50. 


22      Henry  C.  Lea's  Son  &  Co.'s  Publications — {Dis.  of  Women). 


rpHOMAS  {T.GAILLARD),M.D., 

-*■  Professor  of  Obstetrics,  &c. ,  in  the  College  of  Physicians  and  Surgeons,  N.  T.,  Ac. 

A  PRACTICAL  TREATISE  ON  THE  DISEASES  OF  WOMEN.    Fifth 

edition,  thoroughly  revised  and  rewritten.  In  one  large  and  handsome  octa\''0  volume 
of  over  son  pages,  with  2fifi  illustrations.  Cloth,  $5;  leather,  $6;  very  handsome  half 
Russia,  raised  bands,  $6  50.      (Just  Ready.) 

The  author  has  taken  advantage  of  the  opportunity  afforded  by  the  call  for  a  new  edition  of 
this  work  to  render  it  worfhy  a  continuance  of  the  very  remarkable  favor  with  which  it  has 
been  received.  Every  portion  of  the  work  has  been  carefully  revised,  very  much  of  it  has 
been  rewritten,  and  additions  and  alterations  introduced  wherever  the  advance  of  science  and 
the  increased  experience  of  the  author  have  shown  them  desirable.  At  the  same  time  special 
care  has  been  exercised  to  avoid  undue  increase  in  the  size  of  the  volume.  To  accommodate 
the  numerous  additions  a  more  condensed  but  Vi  ry  clear  letter  has  been  used,  notwithstanding 
which,  the  number  of  pages  has  been  increased  by  more  than  fifty.  The  series  of  illustrations 
has  been  extensively  changed  ;  many  which  seemed  to  be  superfluous  have  been  omitted,  and  a 
large  number  of  new  and  superior  drawings  have  been  inserted.  In  its  improved  form,  there- 
fore, it  is  hoped  that  the  volume  will  maintain  the  character  it  has  acquired  of  a  standard 
authority  on  every  detail  of  its  important  subject. 


An  examination  of  the  work  will  satisfy  that  it  is 
one  of  great  merit.  It  is  not  a  mere  compilation 
from  other  works,  but  is  the  fruit  of  the  ripe 
thought,  sound  judgment,  and  critical  observations 
of  a  learned,  scieutiflc  man.  It  is  a  treasury  of 
knowledge  of  the  department  of  medicine  to  which 
it  is  devoted  In  its  present  revised  state  it  cer- 
tainly holdi*  a  foremost  position  as  a  gynfecological 
wok,  and  will  continne  to  be  regarded  as  a  stan- 
dard authority.  —  Cincinnati  3Ted.  News,  Dec.  18S0. 

This  work  needs  no  introduction  to  any  of  the 
civilized  nations  of  the  world.  The  edition  before 
n9  adds  to  the  strength  of  former  volumes.  With 
the  wisdom  of  a  master  teacher  he  here  gives  the 
results  that,  in  his  jadgment,  are  most  trustworthy 
at  the  present  time.  In  its  own  place  it  has  no 
rival,  because  the  author  is  the  best  teacher  on  this 
subject  to  the  masses  of  the  professioa.  As  hitherto 
this  work  will  be  the  text-book  on  diseases  of  wo- 
men. We  only  wish  that  in  other  branches  of  medi- 
cine as  capable  teachers  could  be  found  to  write  our 
text-books. — Detroit  Lancet,  Jan.  ISSl. 

Since  its  first  appearance,  twelve  years  ago,  until 
the  present  day,  it  has  held  a  position  of  high  re- 
gard, and  is  generally  conceded  to  be  one  of  the 
most  practical'  and  trustworthy  volumes  yet  pre- 
sented to  the  physician  and  student  in  the  depart- 
ment ofgynsecology.    The  woik  embodies  not  only 


its  author's  large  experience,  but  reflects  his  care- 
ful study  among  other  authorities  in  this  branch, 
both  at  home  and  abroad  Dr.  Thomas  is  an  able 
and  conscientious  teacher.  His  wri'ings  coovey 
his  meaning  in  the  same  practical  and  instructive 
manner.  The  last  edition  of  this  work  is  fresh  from 
his  pea,  with  decided  changes  and  imarovements 
over  former  editions.  His  book  presents  generally 
accepted  facts,  and  as  a,  guide  to  the  student  is  more 
useful  and  reliable  than  any  work  in  the  language 
on  diseases  of  wnmen.  This  last  edition  will  add 
new  laurels  to  those  already  won.  —  Md.  Med. 
Journ.,  Nov.  15,  1880. 

It  has  been  enlarged  and  carefully  revised.  The 
author  has  brought  it  fully  abreast  with  the  times, 
and  as  the  wave  of  gynsecological  progression  has 
been  widespread  and  rapid  during  the  twelve  years 
that  have  elapsed  since  the  issue  of  the  first  edition, 
one  can  conceive  of  the  great  improvement  this  edi- 
tion must  be  upon  the  earlier.  It  is  a  condensed  en- 
cyclopjedia  of  gyn.a;cological  medicine.  The  style  of 
arrangement,  the  masterly  manner  in  which  each 
subject  is  treated,  and  the  honest  convictions  de- 
rived from  probably  the  larstest  clinical  experience 
in  that  specialty  "^f  any  in  this  country,  all  serve  to 
C'immend  it  in  the  highest  terms  to  the  practitioner. 
— Nashville  Journ.  qf  Med.  and  Surg.,  Jan.  1881. 


B 


ARNES  (ROBERT),  M.D.,  P.R.C.P., 

Obstetric  Physician  to  St.  Thomas's  Hospital,  <te. 

A  CLINICAL  EXPOSITION  OF  THE  MEDICAL  AND  SURGI- 
CAL diseases  OF  WOMEN.  Second  American,  from  the  Second  Enlarged  and  Revised 
English  Edition.  In  one  htind.some  of«tavo  volume,  of  784  pages,  with  181  illustrations. 
Cloth,  S4  50  ;  leather,  $5  50  ;  half  Russia,  $6.      (Just  Issved.) 

the  work  is  a  valuable  one,  and  should  be  largely 
consulted  by  the  profession. — Am.  S^'p'p  Obstetrical 
Journ.  Gt.  Britain  and  Ireland,  Oct.  1S78. 


Dr  Barnes  stands  at  the  head  of  his  profession  in 
the  old  country,  and  it  requires  but  scant  scrutiny 
of  his  book  to  show  that  it  has  been  sketched  by  a 
master.  It  is  plain,  practical  common  sense  ;  shows 
very  deep  research  without  being  pedantic:  is  emi- 
nently calculated  to  inspire  enthusiasm  without  in- 
culcating rajhuesp ;  points  out  the  dangers  to  be 
avoided  as  well  as  the  success  to  be  achieved  in  the 
various  oper^itions  connected  with  this  branch  of 
medicine;  and  will  do  mnch  to  smooth  the  rugged 
path  of  the  young  gynecologist  and  relieve  the  per- 
plexity of  the  man  of  mature  years.  —  Canadian 
Jimrn.  of  Med.  Science,  Nov.  1S7S. 


No  other  gynaecological  work  holds  a  higher  posi- 
tion, having  become  an  authority  everywhere  in 
diseases  of  women.  The  work  has  been  brought 
fully  abreast  of  present  knowledge.  Every  practi- 
tioner of  medicine  should  have  it  upon  the  shelves 
of  his  library,  and  the  student  will  find  it  a  superior 
text-bo  jk. — Cincinnati  Med.  News,  Oct.  1878. 

This  second  revised  edition,  of  course,  deserves  all 
the  commendation  given  to  its  predecessor,  with  the 


I  additional  one  that  it  appears  to  include  all  or  nearly 
We  pity  the  doctor  who,  having  any  consider- i  all  the  additions  to  our  knowledge  of  its  subject  that 
able  practice  in  diseases  of  women,  has  no  copy  of  I  have  been  made  since  the  appearance  of  the  first  edi- 
"  Barnes"  for  datly  consultation  and  instruction.  It  [  tion.  'J'he  American  references  are,  for  an  English 
is  at  once  a  book  of  great  learning,  research,  and  work,  especially  full  and  appreciative,  and  we  can 
individual  experience,  and  at  the  same  time  emi-  j  cordially  recommend  the  volume  to  American  read- 
nently  practical.  That  it  has  been  appreciated  by  ;  ers. — Journ.  of  Nervous  and  Mental  Disease,  Oct. 
the   profession,  both   in   Great   Britain   and  in  this  j  1878. 

country,  is  shown  by  the  second  edition  following  This  second  edition  of  Dr.  Barnes's  great  work 
so  sooa  upon  the  first.-4m.  Practitioner,  Nov.  LjQ^es  to  us  containing  manyadditions  and  impvove- 
■^     "•  meuts  which  bring  it  up  to  date  in  every  feature. 

Dr.  Barnes's  work  is  one  of  a  practical  character,  I  The  excellences  of  the  work  are  too  well  known  to 
largely  illustrated  from  eases  in  hisowu  experience,  !  require  enumeration,  and  we  hazard  the  prophecy 
but  by  no  means  confined  to  such,  as  will  be  learned  that  they  will  for  many  years  maintain  its  high  po- 
from  the  fact  that  he  quotes  from  no  less  than  628  '  sitiou  as  a  standard  text-book  and  guide-book  foj 
medical  authors  in  numerous  countries.  Coming  i  students  and  practitioners.  —  N.  0.  Med.  Journ,, 
from  such  an  author,  it  is  not  necessary  to  say  that ;  Oct.  1878. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Din.  of  Women').      23 


PMMET  {THOMAS  ADDIS),  M.D., 

■^-'  Snrge.rin  to  the  Woman' »  Ho/ipital,  New  York,  etr. 

THE  PRINCIPLES  AND  PRACTICE  OF  GYNECOLOGY,  for  the 

use  of  Students  and  Practitioners  of  Medicine.  Second  Edition.  Thorougly  Revised. 
In  one  large  and  very  handsome  octavo  volume  of  875  pages,  with  133  illustrations. 
Cloth,  $6;   leather,  $6  ;  half  Ru.ssia,  raised  bands,  $6  50.      {Just  Ready.) 

Preface  to  the  Second  Edition. 
The  unusually  rapid  exhaustion  of  a  large  edition  of  this  work,  while  flattering  to  the  author 
as  an  evidence  that  his  labors  have  proved  acceptable,  has  in  a  great  roeiisure  heighcened  his 
sense  of  responsibility.  He  has  therefore  endeavored  to  take  full  advantage  of  the  opportunity 
afforded  to  him  for  its  revision.  Every  page  h.is  received  his  e;irnf.>t  .<ciutiny  ;  the  critici.sics 
of  his  reviewers  have  been  carefully  weighed  ;  ard  whiie  no  ma.  k-^d  increase  has  been  made  in 
the  size  of  the  volume,  several  portions  have  I  een  rewritten,  and  njuch  new  matter  has  been 
added.  In  this  minute  and  thorough  revision,  the  labor  involved  ha.«  been  much  greater  than 
is  perhaps  apparent  in  the  results,  but  it  has  been  cheerfully  e.xpended  in  the  hope  of  rendering 
the  work  more  worthy  of  the  favor  which  has  been  accorded  to  it  by  the  profession. 


lu  no  eountry  of  the  world  has  gyosDCology  re- 
ceived more  atteation  thunin  America.  It  is,  then, 
with  a  feeling  of  pleasure  that  we  welcome  a  work 
on  diseases  of  women  from  so  emiuenl  a  gyoajcolo 
gist  as  Dr.  Emmet,  and  the  work  is  essentially  clini- 
cal, and  leaves  a  strong  impress  of  the  author's  in- 
dividuality. To  criticize,  with  the  care  it  merits, 
the  book  tliroughout,  would  demand  far  more  spacf 
than  is  at  our  command.  In  parting,  we  can  say 
that  the  work  teems  with  original  ideas,  fresh  and 
valuable  methods  of  practice,  and  is  written  in  a 
clear  and  elegant  style,  worthy  of  the  literary  repu- 
tation of  the  country  of  Longfellow  and  Oliver  Wen- 
dell Holmes.— Srii.  3Ied.  Journ,    Feb.  21, 18S0. 

No  gyntecological  treatise  has  appeared  which 
contains  an  equal  amount  of  original  and  uselul 
matter;  nor  does  the  medical  and  surgical  bi.story 
of  America  include  a  hook  more  novel  and  useful. 
The  tabular  and  statistical  information  which  it 
contains  is  marrellous,  both  in  quantity  and  accu- 
racy, and  cannot  be  otherwise  than  invaluable  to 
future  investigators.     It  is  a  work  which  demiind.s 


not  careless  reading,'  but  profound  study.  Its  value 
as  a  cjuiribution  o  gynaecology  is,  perhaps, greater 
than  that  of  all  previous  literature  on  the  subject 
combined. — ChicdQo  3ff.d   Gaz.,  April  6,  ISSO 

The  wide  reputation  of  tie  author  makes  its  pub- 
lication an  event  in  the  gyniecological  world  ;  and 
a  glance  through  its  pages  shows  tbat  it  is  a  work 
to  be  stu'Iied  with  care.  ...  It  must  always  be  a 
work  to  be  carefully  studied  and  frequently  con- 
sulted by  those  who  practise  this  branch  of  our  pro- 
fession.—  Lund.  Med.  Timen  and  Gaz.,  Jan.  10, 18bO. 

Tlie  character  of  the  work  is  too  well  known  to 
require  extended  notice — suffice  it  to  say  that  no 
recent  work  upon  any  subject  has  attained  such 
great  popularity  so  rnpidly  As  a  work  of  general 
reference  upon  the  subject  of  Diseases  of  Women  it 
'S  invaluable.  As  a  record  of  the  largest  clinical 
exuer'ence  and  obseivation  it  has  no  equal.  No 
physician  who  pretends  to  keep  up  with  the  ad- 
vances of  this  department  of  medicine  can  afford  to 
be  without  it. — X/skville  Journ.  of  Medicine  and 
Surgery,  May,  1'80. 


I) 


UNCAN  [J.  MATTHEWS),  M.D.,  LL.D.,  F.R.S.E.,  etc. 

CLINICAL    LECTURES    ON    THE    DISEASES   OF   WOMEN, 

Delivered  in  Saint  Bartholomew's  Hospital.     In  one  very  neat  octavo  volume  of  173 
pages.     Cloth,  $1  50.     (Jv-st  Ready.) 


They  are  in  every  w>iy  worthy  of  their  author  ; 
Indeed,  we  look  upon  them  as  among  the  most  valu- 
ab'e  of  liis  contributions  They  are  all  up  jn  mat- 
ters of  great  interest  to  the  general  practitioner 
Some  of  them  deal  with  subjects  that  are  not,  as  a 
rule,  adequately  handled  in  the  text-books ;  others 
of  them,  while  bearing  upon  topics  that  are  usually 
treated  of  at  length  in  such  works,  yet  bear  such  a 
stamp  of  individuality  that,  if  widely  read,  as  they 
cert?inly  deserve  to  be,  they  cannot  fail  to  exert  a 
wholesome  restraint  upon  the  undue  eagerness  with 
which  many  young  physicians  seem  bent  upon  fol- 
lowing the  wild  teachings  wliich  so  infest  the  gyne- 
cology of  the  present  day. — N.  T.  Med.  Journ., 
March,  1880. 


The  author  is  a  remarkably  clear  lecturer,  and 
his  discussion  of  symptoms  and  treatment  is  full 
and  suggestive.  It  will  be  a  vvork  which  will  n.ot 
fail  to  be  read  with  benefit  by  practitioners  as  well 
a..s  by  sturients.  — P/iiZrx.  Med.  and  Surg.  Reporter, 
Feb.  7,1880. 

We  have  read  this  book  with  a  great  deal  of 
pleasure.  It  is  full  of  good  things.  The  hints  ou 
pathology  and  treatment  scattered  through  the  book 
are  sound,  trustworthy,  and  of  great  value.  A 
healthy  scepticism,  a  large  expeiience,  and  a  clear 
judgment  are  everywhere  manifest.  Instead  of 
bristling  with  advice  of  doubtful  value  and  un- 
sound character,  the  book  is  in  every  respect  a  safe 
guide. —  The  London  Lancet,  Jan..  21,  1880. 


UAMSBOTHAM  [FRANCIS  H.),  M.D. 

THE  PRINCIPLES  AND  PRACTICE    OF  OBSTETRIC  MEDI- 

CINE  AND  SURGERY,  in  reference  to  the  Process  of  Parturition.  A  new  and  enlarged 
edition,  thoroughly  revised  by  the  author.  With  additions  by  W.  V.  Keating,  M.  D., 
Professor  of  Obstetrics,  &c.,  in  the  Jefferson  Medical  College,  Philadelphia.  In  otie  birge 
and  handsome  imperial  octavo  volume  of  650  pages,  strongly  bound  in  leather,  with  raised 
bands  ;  with  sixty-four  beautiful  plates,  and  numerous  wood-cuts  in  the  text,  containing  in 
all  nearly  200  large  and  beautiful  figures.     $7  00. 


^INCKEL  [F.], 

'  '  Professor  and  Director  of  the  GyncBColngical  Clinic  in  the  University  of  Rostock. 

A  COMPLETE  TREATISE  ON  THE  PATHOLOGY  AND  TREAT- 
MENT OF  CHILDBED,  for  Students  and  Practitioners.  Translated,  with  the  consent 
of  the  author,  from  the  Second  German  Edition,  by  James  Read  Chadwick,  M.D.  In 
one  octavo  volume.     Cloth,  $4  00.     (Lately  Issued.) 

JfANNER  [THOMAS  H.),  M.D. 

ON  THE  SIGNS  AND  DISEASES  OF  PREGNANCY.   First  American 

from  the  Second  and  Enlarged  English  Edition.     With  four  colored  plates  and  illustra- 
tions on  wood.    In  one  handsome  octavo  voluiae  of  about  500  pages,  cloth,  $4  26. 


24         Henry  C.  Lea's  Son  &  Co.'s  Vvb-ligatioss— (Midwifery). 


EISHMAN  ( WILLIAM),  M.D., 

Regius  Professor  of  Midwifery  in  the  University  of  aiasgow,  &c 

A  SYSTEM  OF  MIDWIFERY,  INCLUDING  THE  DISEASES  OP 

PREGNANCY  AND  THE  PUERPERAL  STATE.  Third  American  edition,  revised  by 
the  Author,  with  additions  by  John  S.  Parry,  M.D.,  Obstetrician  to  the  Philadelphia 
Hospital,  &o.  In  one  large  and  very  handsome  octavo  volume,  of  733  pages  with  over 
two  hundred  illustrations.    Cloth,  $4  50;  leather,  $5  60  ;  half  Russia,  $6.    {Just  Ready.) 

The  book  is  greatly  improved,  and  as  such  will  be 
welcomed  by  those  who  are  trying  to  keep  posted  in 
the  rapid  advances  which  are  being  made  in  the 
study  of  obstetrics.— £os«ow  Med.  and  Suro.  Journ  . 
Nov   27,  1879. 


Few  works  on  this  subject  have  met  with  as  great 
a  demand  as  this  one  appears  to  have.  To  judge 
by  the  frequency  with  which  its  author's  views  are 
quoted,  and  its  statements  referred  to  in  obstetrical 
literature,  one  would  judge  thai  there  are  fewphy- 
sicians  devoting  much  attention  to  obstetrics  who 
are  without  it.  The  author  is  evidently  a  man  of 
ripe  experience  and  conservative  views,  and  in  no 
branch  of  medicine  are  these  more  valuable  than  in 
this. — New  Remedies,  Jan,  1880. 

We  gladly  welcome  the  new  edition  of  this  excel- 
lent textbookof  midwifery.  The  former  editions 
have  been  most  favorably  received  by  the  profes- 
sion on  both  sides  of  the  Atlantic  In  the  prepara- 
tion of  the  present  edition  the  author  has  made  such 
alterations  as  the  progress  of  obstetric  il  science 
seems  to  require,  and  we  cannot  but  admire  the 
ability  with  which  the  task  has  been  performed. 
We  consider  it  an  admirable  text-book  foif  students 
daring  their  attendance  upon  lectures,  and  have 
great  pleasure  in  recommending  it.  As  an  exponent 
of  the  midwifery  of  the  preseut  day  it  has  no  supe- 
rior in  the  English  language. — Canada  Lancet,  Jan. 
leSO. 

To  the  American  student  the  work  before  us  must 
prove  admirably  adapted,  complete  in  all  its  parts, 
essentially  modern  in  its  teachings  and  with  dem- 
on-trations  noted  for  clearness  and  precision,  it  will 
gain  in  favor  and  be  recognized  as  a  work  of  stand- 
ard merit  The  work  cannot  fail  to  be  popular,  and 
is  cordially  recommended.— i\^.  0.  Med.  and  Surg. 
Joxwn  ,  March,  ISSO. 

Leishman's  is  certainly  one  of  the  best  systematic 
workt  on  rnidwitery.  It  is  very  complete  in  all  the 
parts  essential  for  such  a  treati.-e  To  practitioners 
and  sludents  it  is  to  be  strongly  recommended  as  a 
safe  and  reliable  guide  to  the  modern  practice  of 
midwifery.  —  Oana,da  Med.  and  Surg.  Journal, 
March,  18S\ 

This  is  a  book  of  well -eftablished  reputation,  both 
in  England  and  America.  The  present  edition  has 
been  revised  with  care  by  the  dislinguished  author, 
and  supplied  with  such  additions  and  emendations 
a  -  the  rapid  advances  in  obstetrical  science  demand. 
Pacific  Med.  and  Surg.  Journ.,  May,  ISSO. 


This  work  is  a  thoroughly  good  one,  and  is  well 
adapted  to  the  requirements  of  the  practical  obstet- 
rician. It  is  somethir.g  more  than  a  compend  de- 
signed for  the  medical  student:  it  is  a  book  to  be 
studied  by  the  practitioner,  and  it  will  seldom  dis- 
appoint him.  It  is  of  couvenieat  size,  clearly  writ- 
ten, and  eminently  practical.  As  such,  we  heartily 
comnieod  it  to  oar  readers  —St.  Loins  Olin.  Record, 
Jan.  1880. 

We  are  glad  to  call  theattention  of  our  readers  to 
this  new  edition  of  Dr.  Leishman's  well-known 
work,  which  has  already  established  itself  in  gen- 
eral favor  both  in  this  country  and  in  A  merica.  la 
noticing  this  third  edition  we  need  only  direct  at- 
tention to  the  differences  between  it  and  its  prtde 
cessor.  Alth<jugh  carefully  revised  throughout, 
with  not  a  few  additions  iu  various  places,  the  net 
enlargement  amounts  only  to  a  few  pages. —  OLas- 
yow  Med.  Journ.,  Jan.  1880. 

Leishman's  i*  certainly  one  of  the  best  systematic 
works  on  midwifery.  It  is  very  complete  in  all  the 
parts  essential  for  such  a  treatise.  To  practitioners 
and  students  it  is  to  be  strongly  recommended  as 
t,  safe  and  reliable  guide  to  the  modern  practice  of 
midwifery.  —  Canada  Med.  and  Surg.  Journal, 
.March,  ISSO. 

It  has  been  well  and  carefully  written.  The  views 
of  the  author  are  broad  and  liberal,  and  indiraie  a 
well  balanced  judgment  and  matured  mind.  We  ob- 
serve no  spirit  of  dogmatism,  but  the  earnest  teach- 
ing of  the  thout;htful  observer  and  lover  of  Irue 
science.  Take  the  volume  as  a  whole,  and  it  has  few 
equals. — Md.  Med.Joiirn.,  Feb.  18S0. 

Dr.  Leishman  is  loo  well  known  to  the  profession, 
not  only  that  but  to  the  stude.nt  who  is  about  to 
enter  the  profession,  to  need  any  introduction.  Of 
his  work,  we  need  but  say  that  it  is  a  standard, 
sound  aad  practical. — St.  Louis  Courier  of  Med., 
Jan.  1880. 


JpARRV  [JOHN  S.),  M.D., 

Ob.tteirioian  to  the  Philadelphia  Hospital,  Viee-Prest.  of  the  Obstet.  Siciety  of  Philadelphia. 

EXTRA-UTERINE    PREGNANCY:    ITS  CLINICAL  HISTORY, 

DIAGNOSIS,   PROGNOSIS,  AND   TREATMENT.    In  one  handsome  octavo  volume. 
Cloth,  $2  50.     (Lately  Issued.) 


ODOE  [HUGH  L.),  M.D., 

Emeritus  Professor  of  Midwifery,  &c. ,  in  the  University  of  Pennsylvania,  &c . 

THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.     Illus- 

trated  with  large  lithographic  plates  containing  one  hundred  and  fifty-nine  figures  from 
original  photographs,  and  with  numerous  wood-cuts.  In  one  large  and  beautifully  printed 
quarto  volume  of  550  double-columned  pages,  strongly  bound  in  cloth,  $14. 


The  work  of  Dr.  Hodge  is  something  more  than 
a  simple  presentation  of  his  particular  views  in  the 
de  lartment  of  Obstetrics;  it  is  something  more 
than  an  irdinarytreatise  on  midwifery;  it  is,  in  fact, 
a  cyclopaedia  of  midwifery.     He  has  aimed  to  em- 


Dody  in  a  lingle  volume  the  whole  science  and  art  of 
Obstetrics,  in  elaborate  text  is  combined  with  ac- 
curate and  varied  pictorial  illustrations,  so  that  no 
fact  or  principle  Is  left  unstated  or  unexplained. 
— Am.  Med.  Times,  Sept.  3,  1864. 


***  Specimens  of  the  plates  and  letter-press  will  be  forwarded  to  any  address,  free  by  mai 
on  receipt  of  six  cents  in  postage  stamps. 


o 


fHAD  WICK  (JAMES  R.),  A.M.,  M.D. 

A  MANUAL  OF  THE  DISEASES  PECULIAR  TO  WOMEN. 

neat  volume,  royal  12mo.,  with  illustrations.     (Freparwig.) 


In  one 


Henry  C.  Lea's  Son  &  Co.'s  Publications — {Midwifery,  Surgery).    25 


pLAYFAIR  (  W.  S.),  M.D.,  F.R.C.P., 

-*-  Professor  <if  Ohstetrio  Medicine,  in  King's  College,  etc.  etc. 

A  TREATISE  ON  THE  SCIENCE  AND  PRA.CTICE  OF  MTDWIFRRY. 

Third  American  edition,  revised  by  the  author.  Edited,  with  additions,  by  Robkut  P. 
Harris,  M  D.  In  one  handsome  octavo  volume  of  about  700  pages,  with  nearly  2t0 
illustrations.     Cloth,  $4;   leather,  $5;  half  Russia,  $5  60.     {Just  Ready  ) 

EXTRACT    FROM    THE    AUTHOR'S    PREFACE. 

The  second  American  edition  of  my  worl?  on  Midwifery  being  e.vhausted  before  the  corre- 
sponding English  edition,  I  cannot  better  show  my  appreciation  of  the  kind  reception  my  book 
has  received  in  the  United  States  than  by  acceding  to  the  publisher's  request  that  I  .should 
myself  undertake  the  issue  of  a  third  edition.  As  little  more  than  a  year  has  elapsed  since 
the  second  edition  was  issued,  there  are  naturally  not  many  changes  to  make,  but  I  have, 
nevertheless,  subjected  the  entire  work  to  careful  revision,  and  introduced  into  it  a  notice  of 
most  of  the  more  important  recent  additions  to  obstetric  science.  To  the  operation  of  gastro- 
elytrotomy — formerly  described  along  with  the  Caesarean  section — I  have  now  devoted  a  sepa- 
rate chapter.  The  editor  of  the  Second  American  edition,  Dr.  Harris,  enriched  it  with  many 
valuable  notes,  of  which,  it  will  be  observed,  I  have  freely  availed  myself. 

The  medical  profession  has  now  the  opportunity 
of  adding  to  their  stock  of  standard  medical  works 
one  ofthehest  volumes  on  midwifery  ever  pulilishfd. 


The  subject  is  taken  up  with  a  master  hand.  The 
part  devoted  to  laborin  all  its  various  presentations, 
the  management  and  results,  is  admirably  arranged, 
and  the  views  entertained  will  be  found  essentially 
modern,  and  the  opinions  expressed  trustworthy 
The  work  abounds  with  plates,  illustrating  various 
obstetrical  positions  ;  they  are  admirably  wrought, 
and  afford  great  assistance  to  the  student. — N.  0. 
Med.  and  Surg.  Journ.,  March,  1880. 

If  inquired  of  by  a  medical  student  what  work  on 
obstetrics  we  should  recommend  for  liira,  as  pnr 
exr.ellen'-e,  we  would  ui:doubtedly  advise  him  to 
choose  Playfair's.  It  is  of  convenient  size,  but  what 
is  of  chief  importance,  its  treatment  of  the  various 
subjects  is  concise  and  plain.  While  the  discussions 
and  descriptions  are  sufficiently  elaborate  to  render 


a  very  intelligent  idea  of  them,  yet  all  details  not 
necessary  for  t  full  understanding  of  the  subject  are 
omitted. — Qineinnali  Med.  News,  Jan.  ISSO. 

The  rapidity  with  which  one  edition  of  this  work 
follows  another  is  proof  alike  of  its  excellence  and 
of  the  estimate  that  the  profession  has  formed  of  it. 
It  is  indeed  so  well  known  and  so  highly  valued 
that  nothing  need  he  said  of  it  as  a  whole.  All 
things  considered,  we  regard  this  treatise  as  the  very 
best  on  Midwifery  in  the  English  language.— iV^.  Y. 
Medical  Journrrl,' May,  1880 

It  certainly  is  an  admirable  exposition  of  the 
Scienc>  and  Practice  of  MidwiCery.  Of  course  the 
additions  made  by  the  American  editor,  Dr.  R.  P. 
Harris,  who  never  utters  an  idle  word,  and  wiiose 
studious  resenrches  in  some  special  departments  of 
obstetrics  ara  so  well  known  to  the  profession,  are 
of  great  value.  — T/ie  American  Prac.ticioner,  April, 
1880. 


-DARNES  {FANCOURT),  M.D., 

-^-^  Physioia,n  to  the  General  Lying-in  Hospital,  London. 

A  MANUAL  OF  MIDWIFERY  FOR  MIDWIVES  AXD  MEDICAL 

'  "STUDENTS.     With  50  illustrations.     In  one  neat  royal  12mo.  volume  of  200  pages  j 
cloth,  $1  25.     {Now  Ready.) 
The  book  is  written  in  plain,  and  as  far  as  pos- 
sible in  unlechnical  language.  Any  intelligent  mid- 
wife or  medical  student  can  easily  comprehend  the 
directions.     It  will   undoubtedly  fill  a  want,  and 


will  be  popular  with  those  for  whom  it  has  been 
prepared.  The  examining  questions  at  the  hack 
will  bs  found  very  useful. — Cincinnati  Med.  News, 
Aug.  1S79. 


OTIMSON  [LEWIS  A.],  A.M.,  M.D., 

^^  Surgeon  to  the  Presbyterian  Hospital. 

A  MANUAL  OF  OPERATIVE  SURGERY.     In  one  very  handsome 

royall2mo.  volume  of  about  500pages,  with  332  illustrntions  ;  cloth,  $2  50.  {Just  Issued.) 
The  work  before  us  is  a  well  printed,  profusely    performing  them.     The  work  is  handsomely  illus 


illustrated  manual  of  over  four  hundred  and  seventy 
pages.  The  novice,  by  a  perusal  of  the  work,  will 
gain  a  good  idea  of  the  general  domain  of  operative 
surgery,  while  the  practical  surgeon  has  presented 
to  him  within  a  very  concise  and  intelligible  form 
the  latest  and  most  approved  selections  of  operative 
procedure.  Theprecision  ar  d  conciseness  with  which 
the  different  operations  are  described  enable  the 
author  to  compress  an  immense  amount  of  practical 
information  in  a  very  small  compass. — N.  Y.  Medical 
Record,  Aug.  3, 1878. 

This  volume  is  devoted  entirely  to  operative  sur- 
gery, and  is  intended  to  familiarize  thestudent  with 
the  details  of  operations  and  the  different  modes  of 


trated,  and  the  def  criptions  are  clear  and  well  drawn. 
It  is  a  clever  and  useful  volume  ;  every  student 
should  possess  one.  The  preparation  of  this  work 
does  away  with  the  necessity  of  pondering  over 
larger  works  on  surgery  for  descriptions  of  opera- 
tions, as  it  presents  in  anut-shell  just  what  is  wanted 
by  the  surgeon  without  an  elaborate  search  to  find 
it. — Md.  Med  Journal,  Aug.  1878. 

The  author's  conciseness  and  the  repleteness  of 
the  work  with  valuable  illustrations  entitle  it  to  be 
classed  with  the  text-books  for  students  of  operative 
surgery,  and  as  one  of  reference  to  the  practitioner. 
—  Cincinnati  Lancet  and  Clinic,  July  27,  1S7S. 


SK-'EY'S  OPERATIVE  SUKGEKT.  In  1  vol.  8vo. 
cl.,  of  650  pages  ;  withabont  lOOwood-cuts.  $3  26 

COOPER'S  LECTURES  ON  THE  PRINCIPLES  AND 
Practice  OF  StjROERT.  Inl  vol.  8vo.crh,  750  p.  $2. 

GIBSON'S  INSTITUTES  AND  PRACTICE  OF  SUR- 
GERY. Eighth  edit'n,  improved  and  altered.  With 
thirty-four  plates.  In  two  handsome  octavo  vol- 
umes, about  1000 pp., leather. raised  bandf.  S!"  50. 

THE  PRINCIPLES  AND  PRACTICE  OF  SURGERY. 
By  William  Pirrie,F.R.S.E.,  Profes'r  of  Surgery 
in  the  University  ofAberdeen.    Edited  by  Johh 


Neill,  M.D.,  Professorof  Surgery  in  the  Penna, 
Medical  College,  Surg' n  to  the  Pennsylvania  Hos- 
pital,&c.  In  one  very  handsome  octavo  vol.  of 
780  pages,  with  316  illustrations,  cloth,  .$3  75. 

MILLER'S  PRINCIPLESOF  SURGERY.  Fourth  Ame- 
rican,  from  the  Third  Edinburgh  Edition.  In  ore 
large  Svo.  vol.  of  700  pages,  with  340  illustrations, 
cloth,  $3  75. 

MILLER'S  PRACTICE  OP  SURGERY.  Fourth  Ame- 
rican, from  the  last  Edinburgh  Edition  Revised  by 
the  American  editor.  In  onelargeSvo.  vol. of  nearly 
700 pages,  with  364  illustrations:  cloth,  $3  76. 


26 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Surgery). 


fyROSS  [SAMUEL  D.),  M.D., 

^^  Professor  of  Surgery  in  the  Jefferson  Medical  College  of  Philadelphia. 

SYSTEM  OF    SURGERY:   Pathological,  Diagnostic,  Therapeutic, 

and  Operative.   Illustrated  by  upwa.rds  of  Fourteen  Hundred  Engravings.   Fifth  edition, 
carefully  revised  and  improved.    In  two  large  and  beautifully  printed  imperial  octavo  vol- 
umes of  about  2'M)Q  pp.,  strongly  bound  in  leather,  with  raised  bands,  $15  ;   half  Russia, 
raised  bands,  $16. 
The  continued  favor,  shown  by  the  exhaustion  of  successive  large  editions  of  this  great  work, 
proves  that  it  has  successfully  supplied  a  want  felt  by  American  practitioners  and  students.     In 
the  present  revision  no  pains  have  been  spared  by  the  author  to  bring  it  in  every  respect  fully 
up  to  the  day.     To  effect  this  a  large  part  of  the  work  has  been  rewritten,  and  the  whole  en- 
larged by  nearly  one-fourth,  notwithstanding  which  the  price  has  beenkept  at  its  former  very 
moderatf  rate.     By  the  use  of  a  close,  though  very  legible  type,  an  unusually  large  amount  of 
matter  is  londensed  in  its  pages,  the  two  volumes  containing  as  much  as  four  or  five  ordinary 
octavos.    This,  combined  with  the  most  careful  mechanical  execution,  and  its  very  durable  bind- 
ing, renders  it  one  of  the  cheapest  works  accessible  to  the  profession.    Every  subject  properly 
belonging  to  the  iomain  of  surgery  is  treated  in  detail,  so  that  the  student  who  possesses  this 
work  may  be  said  to  have  in  it  a  surgical  library. 


We  aave  seldom  read  a  work  wiih  the  practical 
value  of  which  we  have  been  moreimpresFed.  Every 
chapter  is  3o  concisely  put  together,  that  the  busy 
practitioner,  when  in  difficulty,  can  at  once  find  the 
information  he  requires.  His  work  is  cosmopolitan, 
the  surgery  ot  the  world  belnu;  fully  represented  in  it. 
The  work,  in  fact,  is  so  historically  unprejudiced,  and 
so  eminentlj'practical.that  it  is  almost  a  false  compli- 
ment to  say  that  we  believe  it  to  be  destined  to  occupy 
a  foremost  place  as  a  work  of  reference,  while  a  system 
of  surgery  like  the  present  system  of  surn;ery  is  the 
practice  of  surgeons.  The  printingand  binding  of  the 
work  is  unexceptionable:  indeed,  it  contrasts,  in  the 
latter  respect,  remarkably  with  English  medical  and 
surgical  cloth-bound  publications,  which  are  generally 
so  wretchedly  stitched  as  to  require  re- binding  before 
they  are  anv  time  in  as&.—Dub.  Journ.  of  Med.  Set., 
March,  1874. 

Dr.  Gross's  Surgery,  a  great  work,  ha.s  become  still 
greater,  both  in  size  and  merit,  in  its  most  recent  form. 
The  difference  in  actual  number  of  pages  is  not  more 
than  130,  but.  the  size  ot  the  page  having  been  in- 
creased to  what  we  believe  is  technically  termed  '-ele- 
phaat."tbere  has  been  room  for  considerablendditions, 
which,  together  with  the  alterations,  are  improve- 
ments.— Lond.  Lancet, Nov.  16, 1872. 

It  combines,  as  perfectly  as  possible,  the  qualities  of 
a  text-book  and  work  of  reference.  We  think  this  last 
edition  of  Gross's  "Surgery,"  will  confirm  his  title  ot 


•'  Primus  inter  Pares."  It  is  learned,  scholar-like,  me- 
thodical, precise,  and  exhaustive.  We  scarcely  thinS 
any  living  man  could  write  so  complete  and  faultless  a 
treatise,  or  comprehend  more  solid,  instructive  matter 
in  the  given  number  of  pages.  The  labor  must  have 
been  immense,  and  the  work  gives  evidence  of  great 
powers  of  mind,  and  the  highest  order  of  intellectual 
discipline  and  methodical  disposition  and  arrangement 
of  acquired  knowledge  and  personal  experience. — N.T. 
Med.  Joiirn.,¥eh. ISIS. 

As  a  whole,  we  regard  the  work  as  the  representative 
"System  of  Surgery"  in  the  English  language. — St. 
Louis  Medical  and  Surg.  Jourtt.,  Oct.  1872. 

The  two  magnificent  volumes  before  us  afford  a  very 
complete  view  of  the  surgical  knowledge  of  the  day. 
Some  years  ago  we  had  the  pleasure  of  presenting  the 
first  edition  of  Gross's  Surgery  to  the  profession  as  a 
work  of  unrivalled  excellence;  and  now  we  have  the 
result  of  years  of  experience,  labor, and  study,  all  con- 
densed upon  the  great  work  before  us.  And  to  students 
or  practitioners  desirousof enriching  theirlibrary  with 
a  treasure  of  reference,  we  can  simply  commend  the 
purchase  of  the.se  two  volumes  of  immense  research  — 
Oincinnati  Lancetand  Observer,  Sept.  1872. 

A  complete  system  of  surgery — not  a  mere  text-book 
Df  operations,  but  a  scientific  account  of  surgical  theory 
and  practice  in  all  its  departments. — Brit,  and  For, 
Med.  Chir.  Rev.,  Jan.  1873. 


-Atlanta  Med.  Journ.,  Oct. 


TfT  THE  SAME  AUTHOR. 

A    PRACTICAL  TREATISE   ON  THE  DISEASES,  INJURIES, 

and^Malformations  of  the  Urinary  Bladder,  the  Prostate  Gland,  and  the  Urethra.  Third 
Edition,  thoroughly  Revised  and  Condensed,  by  Samuel  W.  Gross,  M.D.,  Surgeon  to 
the  Philadelphia  Hospital.  In  one  handsome  octavo  volume  o  1574  pages,  with  170  illus- 
trations: cloth,  $4  50.     (.hist  Issued.) 
For  referenceandgeneralinformation,  the  physician 
or  surgeon  can  find  no  work  that  meets  their  necessities 
more  thoroughly  than  this,  a  revised  edition  of  an  ex- 
cellent treatise,  and  no  medical  library  should  be  with- 
out it.    Replete  with  handsome  illustrations  and  good 
ideas,  it  has  the  unusual  advantage  of  being  easily 
comprehended, by  the  reasonable  and  practical  manner 
in  which  the  various  subjects  are  sy.^tematized  and 
arranged     We  heartily  recommend  it  to  the  profession 
as  a  valuable  addition  to  the  importantliterature  of  dis- 


eases of  the  urinary  organs.- 
1S76. 

It  is  with  pleasure  we  now  again  take  up  this  old 
work  in  a  decidedly  new  dress.  Indeed,  it  must  he  re- 
garded as  a  new  book  in  very  many  of  its  parts.  The 
chapters  on  ■'  Diseases  of  the  Bladder,"  "  Prostate 
Body,"  and  "Lithotomy,"  are  splendid  specimens  of 
descriptive  writing;  while  the  chapter  on  "Stricture" 
is  one  of  the  most  concise  and  clear  that  we  have  ever 
read. — New  York  Med.  Journ. ,No\, 1816. 


T>Y  THE  SAME  AUTHOR. 

A   PRACTICAL   TREATISE    ON   FOREIGN   BODIES   IN   THE 

AIR-PASSAGES.     In  1  vol.  8vo.,  with  illustrations,  pp.  468,  cloth,  $2  75. 

T)RUITT  [ROBERT),  M.R.G.S.,  8rc. 

THE  PRINCIPLES  AND  PRACTICE  OF  MODERN  SURGERY. 

A  new  and  revised  American,  from  the  eighth  enlarged  and  improved  London  edition.  Illus- 
trated with  four  hilfiidred  and  thirty -two  wood  engravings.  In  one  very  handsome  octavo 
volume,  of  nearly  700  large  and  closely  printed  pages,  cloth,  $4  00  ;  leather,  $5  00. 


All  that  the  stirgical  student  or  practitioner  could 
desire. — Dublin  Quarterly  Journal. 

It  is  a  most  admirable  book.  We  do  not  know 
vhen  we  have  examined  one  with  more  pleasure. — 
Boston  Med.  and  Surg.  Jorirnal. 

In  Mr. Drnitt's book, though  containingonly  some 
seven  hundred  pages,  both  the  principles  and  the 


practice  of  surgery  are  treated,  and  so  clearly  and 
perspicuously,  as  to  elucidateevery important  topic. 
We  aave  examined  thebook  most  thoroughly,  and 
can  iay  that  t  hiss  access  is  well  merited.  His  book, 
moreover,  possesses  the  inestimable  advantages  of 
having  the  subjects  perfectly  well  arranged  and 
classified  and  of  being  written  in  a  style  at  once 
clear  and  succinct. — Am.  Journal  of  Med.  Sciences. 


TIenry  C.  Lea's  Son  &  Co.'s  Publications — (Surgery). 


21 


TJAMILTON  [FRANK  H.)  M.D.,  LL.D., 

-^-*-  Surgeon  to  the  Bf.lli'vue  HoK/nlal.  A'eio  Turk. 

A  PRACTICAL  TREATISE  ON  FRACTURES  AND  DISLOCA- 

TIONS       Sixth  edition,  thoroughly  revised,  and  mu'-h  improved.     In  one  very  handsome 
octavo  volume  of  over  900   piiges,  with  352   illustrations.     Cloth,  $5.50;    leather,  $6.50; 
half  Russia,  raised  bands,  $7  00. 
The  demand  which  has  so  speedily  exhausted  five  large  editions  of  this  work,  shows  that  the 
author   has  succeeded  in  supplying  a  want,  felt  by  the  profession  at  large,  of  an   exhaur^tive 
treatise  on  a  frequent  and  troublesome  class  of  accidents.     The  unanimous  voice  of  the  profes- 
sion abroad,  as  well  as  at  home,  ha.'-  pronounced  it  the  most  complete  work  to  which  the  .surg«on 
can  refer  for  information  respecting  the  details  of  the  subject.     In  the  preparation  of  this  new 
edition,  the  author  has  added  a  chapter  on  General  Prognosis:  that  on  Fractures  of  the  Patella 
has  been  entirely  rewritten,  in  order  thnt  the  results  of  a  recent  exhaustive  study  of  this  sub- 
ject might  be  given,  and,  in  fact,  the  entire  matter  of  the  book  has  undergone  most  thorough 
revision.      A  number  of  illustrations  have  been  omitted  to  mtike  place  for  new  ones,  and  a  few 
have  been  inserted  from  the  German  edition,  published  at  Gotlingen  in  1877. 

So  many  kind  expiessiouH  of  welcome  have  lieeu 
sliowert'd  upon  each  successive  ediiiun  of  Ihis  val 


ua-ble  treaii.be,  that  scarcely  ^myihing  leiuains  for 
u.s  to  ilo  but  to  expend  the  caBtornary  cordial  greet- 
ing. It  is  the  only  complete  work  oa  the  subject 
of  Fractures  in  the  English  language.  We  coa- 
gratnlate  the  accomplished  author  on  the  deser/ed 
success  of  his  work,  and  hope  thai  he  may  live  to 
have  many  succeeding  editions  pass  under  his  skill- 
ed supervision. — Phila.  Coll.  and  Clin.  Revurd, 
Nov.  lo,  1880. 

Dr  Hamilton  has  devoted  great  labor  to  thestudy 
of  these  subjects.  His  large  experience,  extended 
research,  und  patient  investigation  have  made  him 
one  of  the  highest  authoritips  among  living  writers 
in  this  branch  of  surgery.  This  work  is  systematic 
and  practical  in  its  arrargement.  and  presents  its 
subject  matter  clearly  and  d  rcibly  to  the  reader 
or  student. — Maryland  Medical  Journal,  Nov. 15, 
1880. 

The  only  complete  work  on  Us  subject  in  the  Eoa- 
lish  tongue,  and,  indeed,  may  now  be  said  to  be 
the  only  work  of  its  kind  in  nuy  tongue.  It  wt'Uld 
require  an  exceedingly  critical  rxamiuation  to  de- 
tect in  it  any  particulars  in  which  it  might  be  im 


proved.  The  work  is  a  monument  to  American 
suri;c-ry,  and  will  long  serve  to  keop  green  ihe 
memory  of  its  veaerabJe  author.—  Michigan  Med. 
News,  Nov.  10,  ISS  . 

Universal  verdict  has  pronounced  it,  humanly 
speaking,  a  periei  t  treatise  upon  this  subject.  As 
it  is  the  (jnly  complet-  and  illustrated  work  in  any 
language  tre^  tiug  of  fractnre^  and  dislocations,  it 
is  safe  to  ifflrm  that  every  wide-awake  surgeon  and 
geueral  practitioner  will  regard  it  as  iudispeasable 
to  the  safe  and  pleasaot  conduct  of  th.ir  profes- 
sional work — Detroit  Lancet,  Nov.  18,  1!<80. 

The  book  is  known  to  he  iheonly  complete  treati  e 
in  the  Engli-h  language,  or  in  any  language,  and 
needs  do  recommeudalion.  If  there  shduld  s<ill 
be  a' surgeon  who  does  not  have  the  book  in  bis 
library,  we  advise  him  to  get  it  immediately. — 
Buffalo  Med.  aiid  Surg.  Journ.,  Dec.  ISSO. 

Thi^~  is  the  sixth  edition  of  the  only  work  extant 
devoted  excluively  to  fraciures  and  disloc.itioiis. 
That  no  ambiiiuus  surgeon  has  aspired  to  enter  this 
field  as  a  rival  to  Trof.  Hamilton  is  ample  tesli- 
muuy  to  the  horoiighness  and  completene.ss  with 
which  be  has  done  his  work.  — O/iio  Med.  Recorder, 
Dec    18«0. 


A  SEHURST  [JOHN,  Jr.),  M.D., 

•^^  Prof,  nf  Clinical  Surgery,  Univ  of  Pa.,  Surgeon  to  the  Episcopal  Hospital,  Philadelphia. 

THE   PRINCIPLES  AND  PRACTICE  OF  SURGERY.     Second 

edition,  enlarged  and  revised.     In  one  very  large  and  handsome  octavo  volume  of  over 
1000  pages,  with  642  illustrations.    Cloth,  $6;  leather,  $7;    half  Russia,  $7.50.     (Just 
Ready.) 
Conscientiousness  and  thoroughness  are  two  very  I      Ashhnrat's   Surgery  is  too   well    known    in   this 

marked  traits  of  character  in    the  author  of  this  |  country  to  require  special   commendation  from  us.  . 

book.     Out  of  these  traits  largely  has   grown   the  i  This,  its  second   edition,  enlarged  and  thoroughly 


success  of  his  mental  fruit  In  the  past,  and  the  pre- 
sent offer  seems  in  no  wise  an  exception  to  what  has 
gone  before.  The  general  arrangement  of  the  vol- 
ume is  the  same  as  in  the  first  edition,  hut  every  part 
has  been  carefully  revised,  and  much  new  matter 
added.— P^i/a.  Med.  Times,  Feb.  1,  1S79. 

We  have  previously  spoken  of  Dr.  Ashhurst's 
work  in  terms  of  praise.  We  wish  to  reiterate  those 
terms  here,  and  to  add  that  no  more  satisfactory 
representation  of  modern  surgery  has  yet  fallen 
from  the  press.  In  point  of  judicial  fairness,  of 
power  of  Condensation,  of  accuracy  and  conciseness 
of  expression  and  thoroughly  good  English,  Prof. 
Afihhurst  has  no  superior  among  the  surgical  writers 
in  America. — Am.  Practitioner,  Jan.  1879. 

The  attempt  to  embrace  in  a  volume  of  1000  pages 
the  whole  field  of  surgery;  general  and  special, 
would  be  a  hopeless  task  unless  through  the  most 
tireless  industry  in  collating  and  arranging,  and 
the  wisest  judgment  in  condensing  and  excluding. 
These  facilities  have  been  abundantly  employed  by 
the  author,  and  he  has  given  us  a  most  excellent 
treatise,  brought  up  by  the  revision  for  the  second 
edition  to  the  latest  dale.  Of  course  this  book  is  not 
designed  for  specialists,  but  as  a  course  of  general 
surgical  knowledge  aud  for  general  practitioners, 
and  as  a  text-book  for  students  it  is  not  snrpasse.i 
by  any  that  has  yet  appeared,  whether  of  h..ineor 
foreign  authorship. — N.  Carolina  Med.  Journal, 
Jan.  1879. 


revised,  brings  it  nearer  our  idea  of  a  model  text- 
book than  any  recently  published  treatise.  Though 
numerous  addirious  have  been  made,  the  size  of  the 
work  is  not  materially  increased  The  main  trouble 
of  text  books  of  modern  times  is  that  they  are  too 
cumbersome.  The  student  needs  a  book  which  will 
furnish  him  the  most  information  in  the  shortest 
time.  In  every  respect  this  work  of  Ashhurst  is 
the  model  textbook-  full,  comprehensive  and  com- 
pact.— Nashville  Jour,  of  Med.  and  Surg.,  Jan.  '79. 

The  favorable  Vtception  of  the  first  edition  is  a 
guarantee  of  the  popularity  of  this  tijition,  which  is 
fresh  from  the  editor's  hands  with  many  enlarge- 
ments and  improvements.  The  author  of  this  work 
is  deservedly  popular  as  an  editor  and  writer,  and 
his  contributions  to  the  literature  of  surgery  have 
gained  for  him  wide  reputation.  The  volume  now 
offered  the  profession  will  add  new  laurels  to  those 
already  won  by  previous  contributions.  We  can 
only  add  that  the  work  is  well  arranged,  filled  with 
practical  matter,  and  contains  in  brief  and  clear 
language  all  that  is  necessary  to  be  learned  by  the 
student  of  surgery  whilst  in  attendance  upon  lec- 
tures, or  the  general  practitioner  in  his  daily  routine 
practice. — Md.  Med.  Journal,  Jan.  1879. 

The  fact  that  this  work  has  reached  a  second  edi- 
tion so  very  soon  after  the  publication  of  the  first 
one,  ppeak.s  more  highly  of  its  merits  than  anything 
wh  might  say  in  the  way  of  co'mmendation.  It 
seems  to  have  immediately  gained  the  favor  of  stu- 
dents and  physiciaus. — Cincin.  Med.  News,  Jan.  '79. 


28 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Surgery). 


jyRYANT  [THOMAS),  F.R.C.S., 

J-^  Surgeon  to  Guy'' s  Hospital. 

THE  PRACTICE  OE  SURGERY.     Third  American,  from  the  Sec- 

ond  and  Revised  English  Edition.     Thoroughly  revised  and  much  improved,  by  John  B. 
Roberts,  M.D.      In  one  large   and  very  handsome  imperial    octavo  volume  of  over  lOdO 
page?,  with  672  illustrations.     Cloth,  $6  60;  leather,  $7  60  ;  very  handsome  half  Russia, 
raised  bands,  $8  00.     (Just  Ready.) 
The  marked  success  of  this  work  on  both  sides  of  the  Atlantic  show.s  that  the  author  has  suc- 
ceeded in  the  effort  to  give  the  student  and  practitioner  a  sound  and  trustworthy  guide  in  the 
practice  of  surgery. 

In  preparing  a  new  edition,  it  has  seemed  best,  in  orr^er  to  adapt  the  work  more  thoroughly  to 
the  needs  of  the  native  student,  that  it  should  receive  the  benefits  of  a  revision  by  an  American 
editor,  who  should  not  only  incorporate  the  most  recent  discoveries,  but  also  the  modes  of  pro- 
cedure, which  must  necessarily  vary  with  the  p'actices  of  different  countries. 

The  work  is  now  confidently  presented  as  worthy  a  cotitinuance  of  the  very  distinguished  suc- 
cess which  has  marked  the  reception  of  the  previous  editions. 


LJRICHSEN  [JOHN  E. ), 

Professor  of  Surgery  in  University  College,  London,  etc. 

THE  SCIENCE  AND  ART  OF  SURGERY ;  being  a  Treatise  on  Snr- 

gical  Injuries,  Diseases,  and   Operations.       Carefully  revised   by  the  author  from  the 
Seventh  and  enlarged  English  Edition.    Illustrated  by  eight  hundred  and  sixty  two  en- 
gravings on  wood.     In  two  large  and  beautiful  octavo  volumes  of  nearly  2000  pages  : 
cloth,  $8  50  ;  leather,  $10  50  ;  half  Russia,  $11  50.     (Novj  Ready.) 
The  seveath  editioa  Is  before  the  world  as  the  last  i  rial  that  has  been  added.     Aside  from  this,  one  hun- 


Wi>i-d  of  sargical  science.  There  may  be  moaographs 
which  excel  it  upon  certain  points,  but  as  a  con- 
spectus upon  surgical  principles  and  practice  It  is 
uarivalled.  It  will  well  reward  practitioners  to 
read  it,  for  it  Las  been  a  peculiar  province  of  Mr. 
Erichsen  to  demonstrate  the  absolute  interdepend- 
ence of  medical  and  surgical  science  We  need 
scarcely  add,  in  conclasiou,  that  we  heartily  com- 
mend the  work  to  students  that  they  may  be 
grounded  in  a  sound  faith,  and  to  practitioners  as 
an  invaluable  guide  at  the  bedside. — Am.  Practi- 
tioner, April,  1878. 

It  is  no  idle  compliment  to  say  that  this  is  the  Oest 
edition  Mr.  Erichsen  has  ever  produced  of  his  well- 
kcown  book.  Besides  inheriting  the  virtues  of  iis 
predecessors,  it  possesses  excellences  quite  its  own. 
Having  stated  that  Mr.  Erichsen  his  incorporated 
into  this  edition  every  recent  improvement  in  the 
science  and  art  of  surgery,  it  would  be  a  supereroga- 
tion to  give  a  detailed  criticism.  In  short,  we  un- 
hesitatingly aver  that  we  know  of  no  other  single 
Work  where  the  student  and  practitioner  can  gain  at 
once  so  clear  an  insight  into  the  principles  of  surgery, 
and  so  complete  a  knowledge  of  the  exigencies  of 
surgical  practice.— iondora  Lancet, 'S'db.Xi,  1878 

For  the  past  twenty  years  Erichsen's  Surgery  has 
maintained  its  place  as  the  leading  text-book,  not  only 
in  this  country,  but  in  Great  Britain.  That  it  is  able 
to  hold  its  ground,  is  abundantly  proven  by  the  tho- 
roiighaess  with  which  the  present  edition  has  been 
revised,  and  by  the  large  amount  of  valuable  mate- 


dred  and  fifty  new  illustrations  have  been  inserted, 
including  quite  a  nnmber  of  microscopical  appear- 
ances of  pathological  processes.  So  marked  is  this 
change  for  the  better,  that  the  work  almost  appears 
as  an  entirely  new  one. — Med.  Record,  Feb.  23,1878. 

Of  the  many  treatises  on  Surgery  which  it  has  been 
our  task  to  study,  or  our  pleasure  to  read,  there  is  none 
which  in  all  points  has  satislied  us  so  well  as  the  classic 
treatise  of  Erich.sen.  His  polished,  clear  style,  his  free- 
dom from  prejudice  anil  hobbies,  his  unsurpassed  grasp 
of  his  subject,  aud  vast  clinical  experience,  qualifj  him 
admirably  to  write  a  model  text-book.  When  we  wish, 
at  the  least  cost  of  time,  to  learn  the  most  of  a  topic  in 
surgery,  we  turn,  by  preference,  to  his  work.  It  is  a 
pleasure,  therefore,  to  see  that  the  appreciation  of  it  is 
general,  and  has  led  to  the  appearance  of  another  edi- 
tion.— Me.d.  and  Surg.  Repurte.r,  Feb.  2, 1878. 

Notwithstanding  the  increase  in  size,  we  observe  that 
much  old  matter  has  been  omitted.  The  entire  work 
has  been  thoroughly  written  up,  and  not  merely  amend- 
ed by  a  few  extra  chapters  A  great  improvement  has 
been  made  in  the  illustrations.  One  hundred  and  tifty 
new  ones  have  been  added,  and  many  of  the  old  ones 
have  been  redrawn.  The  author  highly  appreciates  the 
favor  with  which  his  work  has  been  received  by  Ameri- 
can surgeons,  and  has  endeavored  to  render  his  latest 
edition  more  than  ever  worthy  of  their  approval.  That 
he  has  succeeded  admirably,  must,  we  think,  be  the 
general  opinion.  We  heartily  recommend  the  book  to 
both  student  and  practitioner. — N.  Y.Med.  Journal, 
Feb. 1878. 


// 


OLMES  {TIMOTHY),  M.D., 

Surgeon  to  St.  George's  Hospital,  London. 

SURGERY,  ITS  PRINCIPLES  AND  PRACTICE.    In  one  hand- 

some  octavo  volume  of  nearly  1000  pages,  with  411  illustrations.  Cloth,  $6;  leather,  $7  ; 
half  Russia,  $7  50,     (Just  Issued.) 


This  is  a  work  which  has  been  lookedfor  on  both 
sides  ofthe  Atlantic  with  much  interest.  Mr.  Holmes 
is  a  surgeon  of  large  and  varied  experience,  and  one 
of  the  best  known,  and  perhaps  the  most  brilliant 
writer  upon  surgical  subjects  in  England.  It  is  a 
book  for  students — and  an  admirable  one — and  for 
the  busy  general  practitioner.  It  will  give  a  student 
all  the  knowledge  needed  to  pass  a  rigid  examina- 
tion. The  book  fairly  justifies  the  high  expectations 
that  were  formed  of  it.  Its  style  is  clear  and  forcible, 
even  brilliant  at  times,  and  the  conciseness  needed 
to  bri  ng  it  within  its  properlimits  has  not  impaired 


its  force  and  distinctness. — if.  T.  Med.  Record,  April 
14,  1876. 

It  will  be  found  a  most  excellent  epitome  of  sur- 
gery by  the  general  practitioner  who  has  not  the 
time  togiveattentionto  more  minute  and  extended 
works  and  to  the  medical  student.  In  fact,  we  know 
of  no  one  we  can  more  cordially  recommend.  The 
author  has  succeeded  well  in  giving  a  plain  and 
practical  account  of  each  surgical  injury  and  dis- 
ease, and  of  the  treatment  which  is  most  com- 
monly advisable.  It  will  no  doubt  become  a  popu- 
lar workin  the  profession,  and  especially  as  a  text- 
book.— Cincinnati  Med.  News,  April,  1876. 


ASHTON  ON  THE  DISEASES,  INJURIES,  and  MAL- 
FORMATIONS OF  THE  RECTUM  AND  ANUS: 
with  remarks  on  Habitual  Constipation.  Second 
American,  from  the  fourth  and  enlarged  London 
Edition.  With  illustrations.  In  one  8vo.  vol.  ol 
287  pages,  cloth, $3  26. 


SARGENT  ON  BANDAGING  AND  OTHER  OPERA- 
TIONS OF  MINOR  SURGERY.  New  edition,  with 
an  additional  chapter  on  Military  Surgery.  One 
12mo.  vol.  of  383pag9s  withlSl  wood-cuts  Cloth, 
*176. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Ophthalmology). 


29 


VTELLS  ( J.  SOELBERO), 

'  '  Pro/e/isor  of  Ophthalmology  in  King's  College  Hospital,  4c. 

A  TREATISE  ON    DISEASES  OP  THE  EYE.     Third  American 

from  the  Third  London  Edition.  Thoroiighl.v  revised,  with  copious  nddiii.,nf.  by  Ch;i8.' 
S.  Bull,  M  D. ,  Surgeon  and  Pathologi,st  to  the  Kew  York  Eye  and  Ear  Infirmary.  Iljug! 
trated  with  about  260  ^ngravingt  on  wood,  and  six  coloredplates  Together  with  selec- 
tions from  the  Test-types  of  Jaeger  and  Snellen  In  one  large  and  very  handsome 
octavo  volume  of  900  pages.  Cloth,  $^5;  leather,  $C  ;  half  Rustia,  raised  bands,  $6.50. 
(Just  Ready.) 

The  long-continued  illness  of  the  author,  with  its  fatnl  termin-tion,  has  kept  this  work  for 
some  time  out  of  print,  and  has  deprived  it  of  tlie  advantage  of  the  revi.-ion  which  he  sought 
to  give  it  during  the  last  years  of  hi  life.  This  edition  has  therefore  been  plaed  under  the 
tdiioiial  supervision  of  Dr.  Bull,  who  has  labored  earnestly  to  iniroduct  in  it  all  the  advances 
wh  eh  observation  and  experience  have  acquired  for  the  theory  and  practice  of  oj.bthalmology 
since  the  appearance  of  the  last  revision.  To  accomp  ish  this,  considerable  additions  have  been 
required,  and  the  work  is  now  presented  in  the  contident-e  that  it  will  fully  deserve  a  continu- 
ance of  the  very  marked  favor  with  which  it  has  hitherto  been  greeted  as  a  complete,  but  con- 
cise, exposition  of  the  principles  and  facts  of  its  impo.tant  department  of  medical  science. 

The  additions  made  in  the  previous  American  editions  by  Dr.  Hays  have  been  retained, 
including  the  very  full  series  of  illustrations  and  the  test-types  of  Jaeger  and  Snellen. 

This  uew  edition  of  Dr.  Wells's  great  wuik  on  ihe 
ey3  Hill  be  welcomed  by  the  prol'ession  at  large  ac 
wel.  as  by  the  oculist.    It  coLtainsuiuth  new  m    tte 


rtilaiiug  to  treatment  and  pathology,  aud  is  broiiglji 
thoroughly  up  with  the  pre  ent  status  of  oplithai- 
in-iiogy.  Its  chapter  on  retraction  aud  accommo- 
oaliuu — a  subject  much  discussed  of  late  y^ai-s,  and 
of  great  Importance — is  exceedingly  complete. — 
Louisville  Med.  Ntws,  Nov.  13,  ISSO. 

Tbe  merits  of  Wells's  treatise  on  diseases  of  the 
eye  have  been  so  universally  acknowledged  and  are 
so  familiar  to  all  who  profess  to  have  givpn  any  at- 
leuiion  to  ophthalmic  surgery,  that  any  discussion 
of  them  at  this  late  day  will  be  a  work  of  superero- 
gation. Very  little  that  is  practically  useful  in  re- 
cent ophthalmic  literature  has  escaped  the  editor, 
aud  the  third  American  edition  is  well  up  to  the 
times.  As  a  text-book  on  oph.halmic  surgery  for  the 
liUglish-speakicg  practitioner,  it  is  without  a  rival. 
— Ani.-Journ.  of  Med.  Sci.,  Jan.  1881. 

The  work  has  justly  held  a  high  place  in  English 
•  ophthalmic  literature,  and  at  the  time  of  its  first  ap- 
pearance was  the  best  treatise  of  its  kind  in  the  lan- 


guage. In  the  second  edi:ion,  the  author  showed 
iuilu.siri>;u^  research  iu  adding  new  materia  from 
evtiy  (^iianer,  and  bis  spirii  w<is  eiiiiutnily  candid. 
A  Work  thus  built  up  by  honest  efl'.it  should  not  be 
suffered  to  die,  and  we  are  pleased  t  ■  rec-ire  this 
third  edition  from  the  bauds  of  Or.  Bull.  His  labor 
h  iS  been  ardnons  as  ihe  very  great  number  of  addi- 
tions braeketau  with  his  initial  teoiify.  Under 
the  editorship  which  the  third  edition  has  enjoyed, 
the  Work  is  sure  to  sustain  iis  jiood  lepuialion,  and 
to  maintain  its  usefulness. — A\  r.  Me'J.Journ.,  Jan. 
ISSl. 

There  is  really  no  work  which  approaches  it  in 
adaptation  to  tht  wauls  of  the  general  practitioner, 
while  tlie  most  advanced  specialist  taunoc  ri-e  frnm 
a  perusal  of  its  ample  pages  wi  hout  having  added 
to  his  knowledge.  The  American  editor,  Or.  Bull, 
won  his  spurs  in  ophthalmology  ^ome  time  back. 
His  additions  lo  the  work  of  the  lamented  Wells  are 
many,  judicious,  aud  timely,  and  in  just  so  much 
have  adaed  to  its  value. — Ath.  PractUiontr,  Jan. 
ISSl. 


ATE TTLESHIP  {ED  WARD),  F.R. G.S., 

-^  '  ophthalmic  Surg,  and  Led.  on  Ophth.  Surg,  at  St.  Thomas'  Hospital,  London. 

MEDICINE.     In  one  royal  12mo. 

Cloth,  $2.     (Just  Ready.) 


MANUAL   OF    OPHTHALMIC 

volume  of  over  350  pages,  with  89  illustrations. 


The  author  is  to  be  congratulated  upon  the  very 
successful  manner  in  which  he  has  accomplished  his 
task;  he  has  succeeded  in  being  concise  without 
sacrilicing  clearness,  and,  including  the  whole 
giound  covered  by  more  voluminous  text-books, 
has  given  an  excellent  risvmi  of  all  the  practical 


informatioa  they  contain.  We  do  not  hesitate  to 
pronounce  Mr  INettleship's  book  the  best  manual  on 
ophihalmic  surgery  for  the  use  of  students  and 
'•  busy  practitioners"  with  which  we  are  acquain- 
ted. ~Am.  Jour.  Med.  Sciences,  April,  1S80. 


G- 


'ARTER  {R.  BRUDENELL),  F.R.C.S., 

ophthalmic  Surgeon  to  St.  George's  Ho.fpital,  etc. 

A  PRACTICAL  TREATISE  ON  DISEASES  OF  THE  EYE.  Edit- 
ed, with  test-types  and  Additions,  by  John  Green,  M.D.  (of  St.  Louis,  Mo.).  In  one 
handsome  octavo  volume  of  about  600  pages,  and  124  illustrations.  Cloth,  $3  75.  (Just 
Issued.) 

chapter  is  devoted  to  a  discussion  o  f  the  u  ses  an  d  selec- 
tion ofspectai:les,  and  is  adrnirably  compact,  plain,  and 
useful,  especially  the  paragraphs  on  the  treatment  of 
presbyopia  and  myopia.  In  conclusion,  our  thanks  are 
due  the  author  for  manyuseful  hiutsic  the  great  sub- 
ject of  ophthalmic  surgery  and  therapeutics,  a  field 
where  of  late  years  we  glean  but  a  few  <;rains  of  sound 
wheat  from  amass  of  chaff. — iVew  York  Medical  Record, 
Oct.  23, 1875. 


It  is  with  great  pleasure  that  we  can  endorse  the  work 
as  a  most  valuable  contribution  to  practical  ophthal- 
tnologj.  Mr.  Carter  never  deviates  from  the  end  he  has 
In  view,  and  presents  the  subject  in  a  clear  and  concist 
manner,  easy  of  comprehension,  and  hence  the  mort 
valuable.  We  would  especially  commend,  however,  as 
worthy  of  high  praise,  the  manner  iu  which  the  thera- 
peutics of  disease  of  the  eye  is  elaborated,  for  here  the 
author  is  particularly  clear  and  practical,  where  othei 
writers  are  unfortunately  too  often  deficient.  The  final 


B 


ROWNE  [EDGAR  A.), 

Surgeon  to  the  Livt.rpool  Eye  and  Ear  Infirmary ,  and  to  the  Dispensary  for  Skin  Diseases. 

HOW  TO  USE  THE  OPHTHALMOSCOPE.    Being  Elementary  In- 

structionsin  Ophthalmoscopy,  arranged  for  the  Use  of  Students.    With  thirty -five  illustra- 
tions.    In  one  small  volume  royal  12mo.  of  120  pages  :  cloth,  $1.     (Now  Ready.) 


LAURENCE'S  HANDT-BOOK  OF  OPHTHALMIC 
SURGERY,  for  the  use  of  Practitioners.  Second 
edition,  revised  and  enlarged  With  numerous 
lllnsirations.  In  one  very  handsome  octavo  vol- 
ume, cloth,  $2  75. 


LAWSON'S  INJURIES  TO  THE  EYE,  ORBIT, 
AND    EYELIDS:'  their   Immediate  and   Remote 

j  Effects.  With  about  one  hundred  illustrations. 
In    one   very   handsome    octavo   volume,   cloth 

1      i|i3  50. 


30    Henry  C.  Lea's  Son  &  Co.'s  Publications — ^ 


Jurisprudence). 


jyURNETT  {CHARLES  H.),  M.A.,M.D., 

-*-'  Aural  Surg,  to  the  Presb.  Hosp.,  Surgeon-in-char  ge  ofthelnfir.forDis.  of  the  Bar,  Phila. 

THE   EAR,  ITS   ANATOMY,  PHYSIOLOGY,  AND  DISEASES. 

A  Practical  Treatise  for  the  Use  of  Medical  Students  and  Practitioners.  In  one  hand- 
some  octavo  volume  of  615  pages,  with  eighty-seven  illustrations  :  cloth,  $4  60  ;  leather, 
$5  50  I  half  Russia,  ®6  00.     {Now  Ready.) 


Foremost  among  the  numerous  recent  contribu- 
tions to  aural  literature  will  be  ranked  this  work 
of  Dr.  Burnett.  It  is  impossible  to  do  justice  to 
this  volume  of  over  600  pages  in  a  necesharily  brief 
notice.  It  must  suffice  to  add  that  the  book  is  pro- 
fusely and  accurately  illustrated,  the  references  are 
conscientiously  acknowledged,  while  the  result  has 
been  to  produce  a  treatise  which  will  henceforth 
rank  with  the  classic  writings  of  Wilde  and  Von 
Trolsch.  —  The  Land.  Practitioner,  May,  1879. 

On  account  of  the  great  advances  which  have  been 
made  of  late  years  in  otology,  and  of  the  increased 
intf  rest  manifested  in  it,  the  medical  profession  will 
welcome  this  new  work,  which  presents  clearly  and 
concisely  its  present  aspect,  whilst  clearly  indi- 
cating the  direction  in  which  further  researches  can 
be  most  profitably  carried  on.  Dr.  Burn  tt  from  his 
own  matured  experience,  and  availing  himself  of 


the  observations  and  discoveries  of  others,  has  pro- 
duced a  work  which,  as  a  text-book,  stands /nci/e 
princeps  in  our  language.  We  had  marked  several 
pa^isages  as  well  worthy  of  quotation  and  the  atten- 
tion of  the  general  practitioner,  but  their  number  and 
the  space  at  our  command  forbid.  Perhaps  it  is  bet- 
ter, as  the  book  ought  to  be  in  the  hands  of  every 
medical  student,  and  its  study  will  well  repay  the 
busy  practitioner  in  the  pleasure  he  will  derive  from 
the  agreeable  style  in  which  many  otherwise  dry 
and  mostly  unknown  subjects  are  treated.  To  the 
specialist  the  work  is  of  the  highest  value,  and  his 
sense  of  giatitude  to  Dr.  Burnett  will,  we  hope,  be 
proportionate  to  the  amount  of  benefit  lie  can  obtain 
from  the  careful  study  of  the  book,  and  a  constant 
reference  to  its  trustworthy  pages. — Edinbui  gh 
Med.  Jour.,  Aug.  1878. 


mAYLOR  [ALFRED    S.),M.D., 

■^  Lecturer  on  Med.  Jurisp.  and  Chemistry  in  &uy^8  Hospital. 

A  MANUAL  OF  MEDICAL  JURISPRUDENCE.     Eighth. Am eri- 

can  edition.  Thoroughly  revised  and  rewritten.  Edited  by  Joh»  J.  Reese,  M.D.,  Prcf. 
of  Med.  Jurisp.  and  Toxicology  in  the  Univ.  of  Penn.  In  one  large  octavo  volume  of 
933  pages.  Cloth,  $5;  leather,  $6;  half  Russia,  raised  bands,  $6  60.  {Just  Ready  ) 
The  American  editions  of  this  standard  manual  j  is  to  announce,  not  criticize  the  completed  task.  The 
have  for  a  lonu'  time  laid  claim  to  the  attention  of  value  of  the  gem  is  too  weU  known  to  rcquiie  raoie 
the  profession  in  this  country  ;  and  that  the  profes- 
sion has  recognized  this  claim  with  favor  is  proven 
by  the  call  for  frequent  new  editions  of  the  work. 
This  one,  the  eighth,  comes  before  us  as  embodying 
the  latest  thoughts  and  emendations  of  Dr.  Taylir, 
upon  the  subject  to  which  he  devo  ed  his  life,  with 
an  assiduity  and  success  which  made  him  facile 
prinftps  among  English  writers  on  medical  juris- 
prudence. Both  the  author  and  the  book  have 
made  a  mark  too  deep  to  be  afl'ected  by  criticism, 
whether  it  be  censure  or  praise.  In  this  case,  how- 
ever we  should  only  have  to  seek  for  laudatory 
teims.— .4»i.  Journ.  of  Med.  Sei.,  Jan.  1881. 

It  is  not  very  often  that  a  medical  book  reaches  its 
tenth  edition,  or  that  the  last  earthly  labor  is  per- 
formed by  the  author  in  retouching  the  work  that 
first  came  from  his  hand  thirty-five  years  before. 
All  this,  however,  has  happened  in  the  case  of  Dr. 
Taylor  and  his  classical  treatise.  The  pen  dropped 
from  the  grasp  only  when  the  shadows  of  old  age 
were  rapidly  deepening  into  the  darkness  of  death. 
Under  the  circumstances,  all  the  journalist  has  to  do 


than  the  telling  chat  the  mister-hand  has  rebrig 
ened  its  lacets  and  polished  itsaugies  before  leaving 
it  as  his  legacy  to  h's  brethren  in  the  profession. — 
Phila   Med.  times,  Dec.  4,  1S80. 

It  will  sufiice  to  remark  that  this  new  edition 
shows  the  signs  of  jndit;ioas  revision  A  great  i. um- 
ber of  illustrative  medico-legal  cases  which  have 
occurred  since  the  last  edition  was  pu  lished  are 
cited  in  .heir  proper  connection,  and  add  much  to 
the  interest  and  value  of  the  work;  they  comprise 
the  bulk  of  the  additions  to  the  text.  As  an  indica- 
tion of  the  treshnes.  of  the  work,  we  notice  numer- 
ous references  to  medic  -legal  experience  that  has 
transpired  during  the  year  just  ended  ;  among  these 
is  a  commeno  by  the  American  edito  upon  that 
midsummer  madness,  the  Tanner  fasting  exploit  of 
last  Augast.  In  these  features  and  in  others  there 
is  ample  evidence  that  this  admirable  book  will 
maintain  its  high  pUce  as  a  staadard  authority  con- 
cerning iha  matters  of  which  it  itbais.— Boston 
Med.  and  Stirg.  Journal,  Jan.  13,  1S81. 


or  TBE  SAME  AUTHOM. 

THE  PRINCIPLES  AND  PRACTICE  OP  MEDICAL  JURISPRU- 

DENCE.     Second  Edition,  Revised,  with  numerous  Illustrations.    In  two  large  octavo 

volumes,  cloth,  $10  00;  leather,  $12  00 
This  creat  work  isnow  recognized  in  England  as  the  fullest  andmostauthoritativetreatise  on 
everv  department  of  its  important  subject.  In  laying  it,  in  its  improved  form,  before  the  Amer- 
ican'profession,  the  publishers  trust  that  itwill  assume  the  same  position  in  this  country. 

'Y  THE  SAME  AUTHOR. 


B' 


POISONS  IN  RELATION  TO  MEDICAL  JURISPRUDENCE  AND 

MEDICINE.     Third  American,  from  the  Third  and  Revised  English  Edition.     In  one 
large  octavo  volume  of  850  pages  ;  cloth,  $5  60  ;  leather,  $6  50.     {Just  Issued.) 


The  present  is  based  upon  the  two  previous  edi- 
tions;  -'but  the  complete  revision  rendered  necessary 
bv  time  has  converted  it  into  a  new  work."  This 
statement  from  the  preface  contains  all  that  it  is  de- 
sired to  know  in  reference  to  the  new  edition.  The 
works  of  this  author  are  already  in  the  library  of 
every  physician  who  is  liable  to  be  called  upon  for 
medico-legal  testimony  (and  what  one  is  not?),  so  that 
all  that  is  required  to  be  known  about  the  present 
book  is  that  the  author  has  kept  it  abreast  with  the 
times.  What  makes  it  now,  as  always,  especially 
valuable  to  the  practitioner  is  its  conciseiioss  ana 
practical  character,  only  those  poisonous  substances 


being  described  which  give  rise  to  legal  investiga- 
tions.—T^e  Clinic,  Nov.  6,  187.'5. 

Dr.  Taylor  hat  brought  to  bear  on  the  compilation 
of  this  vulume,  stores  of  learning,  experience,  and 
practical  acquaintance  with  his  subject,  probably  far 
beyond  what  any  other  living  authority  on  toxicol- 
ogy could  have  amassed  or  utilized.  He  has  fully 
sustained  his  reputation  by  the  consummate  skill 
and  legal  acumen  he  has  displayed  in  the  arrange- 
ment ot  the  subject-matter,  and  the  result  is  a  work 
on  Poisons  which  will  be  in  dispensable  to  every  stu- 
dent or  practitioner  in  lawand  medicine. — The  Dub- 
lin Journ.  (//  Med  So..,  Oct.  1875, 


Henry  C.  Lea's  Son  &  Co.'s  Publications — C Miscellaneous).       31 


POBERTS  (  WILLIAM),  M.D., 

-*••'  Lecturer  on  Medicine  in  the  Manchester  School  of  Medicine,  etc. 

A  PRACTICAL  TREATISE   ON  URINARY  AND  RENAL  DIS- 

EASES,  including  Urinary  Deposits.  Illustrated  by  numerous  cases  and  engravings.  Third 
American,  from  the  ThirdRevised  and  Enlarged  London  Edition.  In  one  large  and 
handsome  octavo  volume  of  over  600  pages.     Cloth,  $4.     (Just  Ready.) 

rp HO  MP  SON  {SIR  HENRY), 

■^  Surgeon  and  Frofef.sor  of  Clinical  Surgery  to  University  College  Bospital . 

LECTURES  ON  DISEASES  OF  THE  URINARY  ORGANS.  With 

illustrations  on  wood.  Second  American  from  the  Third  English  Edition.  In  one  neat 
octavo  volume.     Cloth,  $2  25.     (Just  Issued.) 

VT  THE  SAME  AUTHOR.  

ON  THE  PATHOLOGY  AND  TREATMENT  OF  STRICTURE  OF 

ThE  URETHB  A  AND  URINARY  FISTULiE.  With  plates  and  wood-cuts.  From  the 
thira  and  revised  English  edition.  In  one  very  handsome  octavo  volume,  cloth,  $3  6U. 
(Lately  Publisked.) 

rrUKE  [DANIEL  HACK),  M.D., 

*■  Joint  author  of  The  Mammal  of  Psychological  Medicine,  &c. 

ILLUSTRATIONS  OF  THE  INFLUENCE  OF  THE  MIND  UPON 

THE  BODY  IN  HEALTH  AND  DISEASE.  Designed  to  illustrate  the  Action  of  the 
Imagination.  In  one  handsome  octavo  volume  of  416  pages,  cloth,  $3  25.  (Lately  Issued .) 

JiLANDFORD  {O.  FIELDING),  M.D.,  F.R.C.P., 

J-f  Lecturer  on  Psychological  Medicine  at  the  School  of  St.  George's  Hospital,  Ac. 

INSANITY  AND  ITS  TREATMENT:  Lectures  on  the  Treatment, 

Medical  and  Legal,  of  Insane  Patients.     With  a  Summary  of  the  Laws  in  force  in  the 
United  States  on  the  Confinement  of  the  Insane.     By  Isaac  Ray,  M.  D.     In  one  very 
handsome  octavo  volume  of  471  pages  ;  cloth,  $3  25. 
It  satisfies  a  want  which  must  have  been  sorely 

felt  by  the  busy  genera  Ipi-actiiioners  of  this  conn  try. 

It  takes  the  form  of  a  manual  of  clinical  description 


of  the  various  forms  of  insanity,  with  a  description 
of  the  mode  of  examining  person.s  suspected  of  in- 
sanity. We  call  particular  attention  to  this  feature 
of  the  book,  as  giving  it  a  unique  value  to  the  gene- 
ral practitioner.  If  we  pass  from  theoretical  conside- 
rations to  descriptions  of  the  varieties  of  Insanity  as 


actually  seen  In  practice  and  the  appropriate  treat- 
ment for  them,  we  tind  in  Dr.  Blaudford's  work  a 
considerable  advance  over  previous  writings  on  the 
subject.  His  pictures  of  the  various  forms  of  mental 
disease  are  so  clear  and  good  that  no  readercan  fail 
to  be  struck  withtheir  superiority  to  thosegiven  in 
jidinary  manuals  in  the  English  language  or  (so  far 
as  our  own  reading  extendsjinany  other. — London 
Practitioner,  Feb.  1871. 


EA  {HENRY  C). 
'superstition   AND   FORCE:    ESSAYS   ON  THE   WAGER   OF 

LAW,  THE  WAGER  OF  BATTLE,  THE  ORDEAL,  AND  TORTURE.  Third  Revised 
and  Enlarged  Edition.  In  one  handsome  royal  12mo.  volume  of  552  pages.  Cloth, 
$2  60.      (Just  Ready) 


This  valuable  work  is  in  reality  a  history  of  civi- 
lization as  interpreted  by  the  pr.  grest,  of  jurispru- 
dence. ...  In  "Sapeistition  and  Force"  we  have 
a  pnilosophic  survey  of  the  long  period  intervening 
between  primitive  barbarity  and  civilized  enlight- 
enment. There  is  not  a  chapter  in  the  work  that 
should  not  be  most  carefully  studied,  and  however 
well  versed  the  reader  may  be  in  the  science  of 
jurisprudence,  he  will  find  much  in  Mr.  Lea's  vol- 
ume of  which  he  was  previously  ignorant.  The 
book  is  a  valuable  addition  to  the  literature  of 
social  science. —  Westminster  Review,  Jan.  18S0. 

The  appearance  of  a  new  edition  of  Mr.  Henry  C. 
Lea's  " Superstition  and  Force"  is  a  sign  that  our 
highest  scholarthip  is  not  without  honor  in  its  na- 
ti  7e  country.    Mr.  Lea  has  met  every  fresh  demand 

for  his  work  with  a  careful  reirision  of  it,  and  the  |  Magazine,  Oct.  187S. 
present  edition  is  not  only  fuller  and,  if  possible. 


more  accurate  than  either  of  the  preceding,  but, 
from  the  thorough  elaboration,  is  more  like  a  har- 
monious concert  and  less  like  a  batch  of  studies 

The  Nation,  Aug.  1,  1878. 

Many  will  be  tempted  to  say  that  this,  like  the 
•'DeclineaudFall,"isone  of  theuncriticizable  books. 
Its  facts  are  innumerable,  its  deductions  simple  and 
inevitable,  and  its  chevaiix-de-frise  of  references 
bristling  and  dense  enough  to  make  the  keenest, 
stoutest,  and  best  equipped  assailant  think  twice 
before  advancing.  Nor  is  there  anything  contro- 
versial in  it  to  provoke  assault.  The  author  is  no 
polemic.  Though  he  obviously  feels  and  thinks 
strongly,  he  succeeds  in  attaining  impartiality. 
Whetler  looked  on  as  a  picture  or  a  mirror,  a  worfe 
such  as    this    has^  a  lasting  value. — Lippincoti' s 


B 


Y  THE  SAME  A  UTHOR. 

STUDIES  IN  CHURCH  HISTORY.    THE  RISE  OF  THE  TEM- 

FORAL  POWER— BENEFIT  OP  CLERGY— EXCOMMUNICATION.    In   one   large 
royal  l2mo.  volume  of  516  pp.;  cloth,  $2  75.     (Lately  FiMished.) 


The  story  was  never  told  more  calmly  or  with 
greater  learning  or  wiser  thought.  We  doubt,  indeed, 
if  any  other  study  of  this  field  can  be  compared  with 
this  for  clearness,  accuracy,  and  power.  —  Chicago 
Examiner ,  Dec.  1870. 

Mr.  Lea's  latest  work,-'  Stndiesin  Church  History," 
fal  ly  sustains  the  promise  of  the  first.  It  deals  with 
three  subjects — the  Temporal  Power,  Benefit  of 
Clergy,  and  Excommunication,  the  record  of  which 


has  a  peculiar  importance  for  the  English  8tudent,and 
is  a  chapter  on  Ancient  Law  likely  to  be  regarded  as 
final.  We  can  hardly  pass  from  our  mention  of  such 
works  as  these — with  which  that  on  "Sacerdotal 
Celibacy"  should  be  included — without  noting  the 
literary  phenomenon  that  theheadof  one  of  the  first 
American  houses  is  also  the  writer  of  some  of  its  most 
original  books. — London  Athenmura,  Jan.  7, 1871. 


32 


Henry  C.  Lea's  Son  &  Co.'s  Publications. 


INDEX   TO    CATALOGUE. 


American  Journal  of  the  Medical  Sciences 

Allen's  Anatomy 

Anatomical  Atlas,  by  Smith  and  Horner 
Ashton  on  the  Rectum  and  Anus 
Attfield's  Chemistry    .... 
Ashwell  on  Diseases  of  Females 

*  Ishhurst's  Surgery      .... 
Browne  on  Ophthalmoscope  . 
Browne  on  the  Throat    .... 
*Burnett  on  the  Ear       .        .    ■    . 

*  Barnes  on  Diseases  of  Women    . 

Barnes'  Midwifery  .... 

Bellamy's  Surgical  Anatomy 

*Bryant'sPractice  of  Surgery    . 

Bloxam's  Chemistry      .... 

Blandford  on  Insanity  .... 

Basham  on  Recal  Diseases  . 

Bartholow  on  Electricity 

Barlow's  Practice  ol  Medicine    . 

Bowman's  (John  E.)  Practical  Chemistr; 

*Bristowe's  Practice       .... 

*Bamstead  on  Venereal 

Biimstead  and  CuUerier'sAtlasof  Venereal 

"■Carpenter's  Human  Physioiogy 

Gctrpenler  on  the  Use  and  Abuse  of  Alcohol 

*Cornil  and  Ranvier       . 

Carter  on  the  Eye  .... 

Cleland's  Dissector 

Classen's  Chemistry 

Clowes'  Chemistry 

Century  of  American  Medicine    . 

Chadwick  on  Diseases  of  Women 

Chambers  on  Diet  and  Kegimen  . 

Christison  and  Gritfith's  Dispensator 

Churchill's  Prac  ice  of  Midwifery 

Churchill  on  Puerperal  Fever 
Condie  on  Diseases  of  Children  . 

Cooper's  (B.  B.)  Lectures  on  Surgery 
Callerier's  Atlas  of  Venereal  Diseases 
Cyclopsedia  of  Practical  Medicine 

Duncan  on  Diseases  of  Women    . 

*Dalton's  Human  Physiology      .        . 

Davis's  Clinical  Lectures 

Dev^es  on  Diseases  of  Females  .        . 

Drnitt's  ModernSnrgery 

*Dungliaon'6  Medical  Dictionary 

Ellis's  Demonstrations  in  Anatomy 
*Erichsen'8  System  of  Surgery    . 

*Emmet  ou  Diseases  of  Women     . 

Farquharson's  Therapeutics 

Foster's  Physiology 

Fenwick's  Diagnosis     .... 
Finlayson's  Clinical  Diagnosis 
Flint  on  Respiratory  Organs        .        .  . 
Flint  on  tlie  Heart         .... 
*  i'lint's  Practice  of  Medicine.      . 

Flint's  Essays 

♦Flint's  Clinical  Medicine     . 

Flint  on  Phthisis 

Flint  00  Percnssjion        .... 

♦Fothergill's  Handbook  of  Treatment 

Fownes's  Elementary  Chemistry 

Fox  on  Diseases  of  the  Skin 

Fuller  on    the  Lungs,  &:c. 

Green's  Pathology  and  Morbid  Anatomy 

Greene's  Medical  Chemistry 

Gibson's  Surgery 

Gluge's  Pathological  Histology,  by  Leidy 

*Gray'8  Anatomy^ 

Galloway's  Analysis       .... 

Griffith's  (R.  E.)  Universal  Formulary 

Gross  on  Urinary  Organs      . 

Gross  on  Foreign  Bodies  in  Air-Passages 

*3ros8'8  System  of  Surgery 

Habershon  on  the  Abdiimen  . 

♦Hamilton  on  Dislocations  and  Fractures 

Hartshorne's  Essentials  ofMediciae  . 

Hartshorne's  Conspectus  of  the  Medical  Science 

Hartshorne's  Anatomy  and  Physiology 

Hamilton  on  Nervous  Diseases    . 

Heath's  Practical  Anatomy 

Hnblyn's  Medical  Dictionary 

Hodge  on  Women  .... 


PAGE 

.       1 
7 

7 
.     28 


PAOB 

.     24 

1-1 

.     28 


21 

27 
29 
19 
30 
22 
2fi 
7 
28 
10 
31 
19 
IS 

u 

g 

14 
20 
20 

8 
11 
13 
29 

7 

9 
10 

5 
24 
19 
II 
21 
21 
21 
2,5 
20 
15 
23 

,9 
15 
21 
26 
4 
7 
28 
23 
11 
8 
14 
18 
19 
19 
15 
15 
15 
19 
19 
16 
10 
18 
19 
14 
9 
25 
13 
6 
9 
11 
26 
26 
26 
14 
27 
16 
i    5 

IS 

6 

4 
21 


ience 


Hodge's  Obstetrics         ... 
Holland's  Medical  Notes  and  Reflections  . 

*Holmes'8  Surgery 

Holden's  Landmarks  .... 

Horner's  Anatomy  and  Histology     ...       7 

Hudson  on  Fever 19 

Hill  on  Venerea]  Diseases    .  ...     20 

Hillier's  Handbook  of  Skin  Diseases  .        .     19 

Cones  (C.  Handfieid)  on  Nervous  Disorders  .  1.8 
Knapp's  Chemical  Technology    .  .         .     10 

Lea's  Superstition  and  Force  ,        .        .31 

Lea's  Studiesin  Church  History  ,        .         .31 

Lee  on  Syphilis 20 

*Leishman'8  Midwifery         ....         .     ^4 

La  Roche  on  Yellow  Fever 14 

La  Roche  on  Pneumonia,  &c 19 

Laurence  and  Moon's  Ophthalmi'- Sarsfery  .     29 

Lawson  on  the  Eye       ...  .        .     20 

Lehmann's  Physiological  Chemistry,  2  vo 

Lehmann's  Chemical  Physiology 

Ludlow's  Manual  of  Examinations    . 

Lyons  on  Fever     . 

Miichell's  Nervous  Diseases  of  Women 

Medical  News  and  Abstract 

Morris  on  Skin  Diseases 

Meigs  on  Puerperal  Fever    .        ,        .     , 

Miller's  Practice  of  Surgery 

Miller's  Principles  of  Surgery     .        . 

Montgomery  on  Pregnancy 

Nettleship's  Ophthalmic  Medicine 

Neil!  and  Smith's  Compendium  of  Med.  S' 

Parry  on  Extra-Uterine  Pregmancy      .     • 

Pavy  on  Digestion        .        "        .         . 

*Parrish's  Practical  Pharmacy   . 

Pirrie's  System  of  Surgery  .         .        . 

*Playfair'8  Midwifery 25 

Quain  and  Sharpey's  Anatomy,  by  Leidy  .  .  7 
♦Reynolds'  System  of  .Medicine  .  .  .  .  '^  7 
Richardson's  Preventive  iMeditiae  .  .  .  16 
Roberts  on  Urinary  Diseases  ....  31 
Ramsbotham  on  Parturition  ....  23 
Remsen'a  Principles  of  Chemistry      ...       9 

Rigby's  Midwifery 21 

Rodwell's  Dictionary  of  Science  .  .  .  .4 
Stimson's  Operative  Surgery  .  ,  .  .25 
Swayne's  Obstetric  Aphorisms    .         .        .        .21 

Seller  on  the  Throat 19 

Sargent's  Minor  Surgery 28 

Sharpey  and  Quain's  Anatomy,  by  Leidy  .        .       7 

Skey's  Operative  Surgery 26 

Slade  on  Diphtheria 19 

Schafer's  Histology  * 7 

*Smith  (J  L.)  on  Children 21 

Smith  (H.  H.)  and  Horner's  Anatomical  Atlas  ,  7 
Smith  (Edward)  on  Consumption        .  .19 

Smith  (Eust  )  on  Wasting  Diseases  in  Children      21 

*Still6's  Therapeutics 13 

*Stille  &  Maisch's  Dispensatory  .  .  .  .12 
Sturges  on  Clinical  Medicine        ....     15 

Stokes  on  Fever .14 

Tanner's  Manual  of  Clinical  Medicine        .        .       5 

Tanner  on  Pregnancy 23 

♦Taylor's  Medical  Jurisprudence  .  .  .30 
Taylor's  Principles  and  Practice  of  Med  Jnrisp  30 
Taylor  on  Poisons  ...     30 

Tuke  on  the  Influence  of  the  Mind  .  .  ,31 
♦Thomas  on  Diseases  of  Females  .  .  .  22 
Thompson  on  Urinary  Organs      .        .        ..        .31 

Thompson  on  Stricture 31 

Todd  on  Acute  Diseases 14 

Woodbury's  Practice 16 

Walsheon  the  Heart 19 

Watson's  Practice  of  Physic       .        .        .        .16 

♦Wellson  the  Eye 29 

West  on  Diseases  of  Females  ....  20 
West  on  Diseases  of  Children  ....  20 
West  on  Nervous  Disorders  of  Children  .  .  20 
Williams  on  Consumption   .  ...     19 

Wilson's  Human  Anatomy 7 

Wilson's  Handbook  of  Cutaneous  Medicine  .  19 
Wiihler's  Organic  Chemistry       ....      9 


WinckelonChildbed 23 


Books  marked  *  are  also  bound  in  half  Russia. 


HENRY  C.  LEA'S  SON  &  CO.— Philadelphia. 


COLUMBIA  UNIVERSITY 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing, 
as  provided  by  the  rviles  of  tlie  Library  or  by  special  ar- 
rangement with  the  Librarian  in  charge. 


DATE  BORROWED 

DATE  DUE 

DATE  BORROWED 

DATE  DUE 

1 

-^hH 

■  ''W-^ 

' 

\    C28(638)M50 

RG524 


P69 
1880 


r/rfatLe  on  the   science  and 
of  midwifery 


pra 


ctice 


